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Site address: }` Date of Testirtg/Senzcin**: - F. In-Tank Gauging / SIR Equipment: ❑ Check this box if tank gauging is used onl} for inventon•control. Check this boa if no tank gauging or SIR equipment is installed- This nstalledThis section must be completed if in-tank- gauging equipment is used to perform leak detection motutorin . Co fete the following checklist: E es ❑ No* Has all input wiring been inspected for proper entry and termination,including testing for ground faults? j es ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? !. "es ' ❑ No* Was accuracy of system product level readings tested? Yes ❑ No* Was accuracy of system water level readings tested? Yes ❑ No* Were all probes reinstalled properly? 16 Yes ❑ No* Were all items on the equipment manufacturers mainienance checklist completed'? * In the Section H, below,describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): ❑ Check this box if LLDs are not installed. Coqrolete the following checklist: Yes ❑ No* For equipment start-up or annual equipment cation, was a leak simulated to verify LLD performance'? ❑ N/A (Check all that apply) Simulated leak rate: 3 g.p.h.`: ❑ 0.1 g p.h_'; ❑ 0.2 g.p.h., Notes: 1. Required for equipment start-up certification and anmlal certification. 2. Unless mandated by local agency,certification required onh•for electronic LLD start-up. Yes ❑ No* , Were all LLDs confirmed operational and accurate within regulatory requirements`' L es ❑ No* Was the testing apparatus properly calibrated? Yes ❑ No* For mechanical LLDs_ does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ o* For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? 9 N/A ❑ Yes ❑ o* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled IN/A or disconnected? ❑ Yes ❑/No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system XN/A malfunctions or fails a test? ❑ Yes ❑ No* For electronic LLDs_ have all accessible wiring connections been visually_ inspected? YN/A Yes ❑ No* Were all items on the equipment manufacturers maintenance checklist compieted? * In the Section H,below,describe how and when these deficiencies were or will be corrected. Ti. Comments: Page 3 of 3 03101