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monitoring System Certification "r/ <br /> Site Address: 4501 N. PERSHING AVE. Date of Testing/Service: 10/102011 <br /> @ ROSEMARIE LN. <br /> F. In-Tank Gauging /SIR Equipment <br /> Check this box if tank gauging is used only for inventory control. <br /> ❑ Check this box if no tank gauging or SIR equipment is installed. <br /> Check this box if no tank gauging or SIR equipment is installed. <br /> This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. <br /> Complete the following checklist: <br /> Yes ❑No' Has all input wiring been inspected for proper entry and termination,including testing for ground faults? <br /> ❑X Yes 1:1 No• Were all lank gauging probes visually inspected for damage and residue buildup? <br /> FXJ Yes ❑No• Was accuracy of system product level readings tested? <br /> QYes ❑No• Was accuracy of system water level readings tested? <br /> _MYes ❑No• Were all probes reinstalled properly? <br /> QYes ❑No• Were all items on the equipment manufacturers'maintenance checklist completed? <br /> 'In the Section H,below,describe how and when these deficiencies were or will be corrected. <br /> G. Line Leak Detectors (LLD) : ❑ Check this box if LLDs are not installed. <br /> Complete the following checklist: <br /> For equipment start-up or annual equipment certification,was a leak simulated to verify LLD performance? <br /> ❑X Yes ❑No ❑NIA (Check all that apply)Simulated leak rate: X❑ 3 g.p.h ❑0.1 g.p.h ❑0.2 g.p.h <br /> X Yes ❑No• Were all LLDs confirmed operational and accurate within regulatory requirements? <br /> F71 Yes ❑No• Was the testing apparatus properly calibrated? <br /> ❑X Yes ❑No• ❑NIA For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> ❑Yes ❑No• x❑NIA For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? <br /> ❑Yes ❑No' X❑N/A For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? <br /> ❑Yes No• ❑X NIA For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? <br /> �❑l Yes ❑No• ❑x N/A For electronic LLDs,have all accessible wiring connections been visually inspected? <br /> LJ Yes ❑No' Were all items on the equipment manufacturersmaintenance checklist completed? <br /> In the Section H,below,describe how and when these deficiencies were or will be corrected. <br /> H. Comments: <br /> Page 3 of 3 Based on CA form dated 03/08 <br />