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Site Address: �. .,: Date of Testittg/Servicing: F. In-Tank Gauging ! SIR Equipment: ❑ Check this box if tank gaging is used only for inventory controL Cheek this box if no tank gauging or SIR equipment is installed This section must be compieted if in-tank gauging equipment is used to perform leak detection monitoring. Co Tete the following checklist: ! if/yes ❑ No* Has all input wiring been inspected for proper entre-and termination. including testing for _round faults? "es ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup" I ©/yes ❑ No* Was accuracy of system product level readings tested? Yes j ❑ No* Was accuracy of system water level readings tested`' Yes ❑ No* Were all probes reinstalled properly`? Yes ❑ No* Were all items on the equipment manufacturer's maintenance 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. Co tete the following checklist: Yes ❑ No* For equipment start-up or annual equipment _ fication_ was a leak simulated to verify_ LLD performance? ❑ N/A !Check all that apply) Simulated leak rate: 0"33 g.p.h.': ❑ 0.1 -.p.h_'; ❑ 0.2 g.p.h.' Notes: 1. Required for equipment start-up certification and annual certification. 2. Unless mandated by local agency.certification required only for electronic LLD start-up. es ❑ No* i Were all LLDs confirmed operational and accurate within regulatory requiremems--.1 i✓ 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 automaticalh_�shut off if the LLD detects a leak? NIA ❑ Yes { ❑ o* For electronic LLDs, does the turbine amomaticalty shut off if any portion of the monitoring system is disabled LL; N/A or disconnected? ❑ Yes ❑/No* For electronic LLDs, does the turbine automaticaUv shut of if any portion of the monitoring system ©(N/A malfunctions or fails a test? ❑ Yes ❑ No* For electronic LLDs_ have all accessible wiring connections been visually_ inspected? YN/A Yes ❑ No* Were alt items on the equipment manufacturer's maintenance checklist completed? In the Section H,below,describe how and when these deficiencies were or will be corrected. H. Comments: Page 3 of 3 --- --- ---- -- - usiat --