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08/24/2004 09:51 91G9277344 CHAMPION PT INC PAGE 05 <br /> i <br /> Site Address: � F��.:�r�ata� <br /> ,.: ?� bate of Testin�Sexvicing: <br /> F. In-Tank Gauging/SIR Equipment: ❑ Check this box ifrank ; <br /> ga4ing is used only for inventory control, <br /> ❑ Check this box if no tack gauging or Skit equipment is uvsialled. <br /> This section trust be completed if in-tank gauging equipment is.used to Perform leak detection motitoring, <br /> C <br /> WOW <br /> ehecas all input wir'irt.beeinspected for proper envy and ttermtnaano4 including testing for ground faults?ere all tankvisually ittspcxted for damage and residrte buildup?as accuracy of systesa pradnrx level redited? <br /> as accau water level readings reared? <br /> ere all probes.tcinsraftedere a1S items on the eg+ripmeW manufa�ter's maimmance checklist cotnpieted? <br /> "Le the Seclinn It,below,describe ltrtw and whenthese defiiedertt:ies were Or well be corrected. <br /> G. Line Leak Detectors (LLD): ❑ Check this lxm if LLDs ate not insralla <br /> C etc the followin checklist <br /> Yes [7 No* For equipment ma-up or auroral equipment ration, was a leak simulated to vc ify LLD <br /> 13 NIA XWeck ail that l S' c. 7 <br /> Petforroauce, <br /> apply) trtrrdated leak ram: � g.p.h. . ❑U.1 gp.h.'; ❑U.2 g.p-h.' <br /> Notes: 1- Required for equipment start-ap ceztificalion and amoral ceuificatian. <br /> Z. Unless mandated by IoxaI agexrcy, xnificadon regm ted only fort electronic LLD srmt-ttp- <br /> ❑ No* Were all LLD6 cou&rmed operational and accurate wdthin regolatmy regnkemetitsY <br /> ❑ No* Was the testing apparatus properly calthaaled? <br /> Yes ❑ No* Fur trtechanital LLDs. does the LLD restrict product.tlow if it detects a leak? <br /> ❑ NIA <br /> ❑ Yes ❑ Nh* For electronic LLAs,does the turbine mrrom,-rbtally shut off if the LLD detects a leak? <br /> gr NIA <br /> ❑ Yes 0 Pia* For ekxamtic LLDs.does the turbine automatically shut off if any portion of the monitoring system is disable3 <br /> N/A ordiscmmected7 <br /> q Yes [3 �— For eiectmnic LLDs, does the tuthiue aommaticaily stmt off a am, portion of the monitrning system <br /> VN/A atalftmetions or fails a test? <br /> Eyes ❑ No* Forelec uoaicLLbs,haveado ac=ssible w atug cotmcb ons beenvlsE WA❑ No* Werc all items on the equipment at purees maintmance oheddist completed? <br /> a In the Section H,below,describe how and when these defir:ieueies were or well be corrected <br /> FL Comments: <br /> Page 3 of 3 nwrn <br />