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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s of 6) XII . LINE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors (LLD) are NOT Installed. (Do not complete this section.) Y N NA This section must be completed if LLDs are Installed. Was a leak simulated to verify LLD performance? ❑ ❑ (Check all that apply.) Simulated leak rate verified: ❑X 3 GPH El 0. 1 GPH El 0.2 GPH RX Was the testing apparatus properly calibrated? N ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? ❑X I ❑ I ❑ For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak Is detected? ❑ I ❑ For electronic LLDs, does the turbine automatically shut off when a leak is detected ? Q ❑ ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑X ❑ ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑X ❑ ❑ For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks? ❑X ❑ ❑ Were all items on the equipment manufacturer's maintenance checklist completed? Q ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? 0 I ❑ ❑ For any answer of "N" above, describe in Section X111 how and when these issues were or will be corrected. X111. COMMENTS , XIV. VACUUM / PRESSURE / HYDROSTATIC ' MONITORING EQUIPMENT TESTING ❑ Check this box if VPH monitoring is NOT used . (Do not complete this section) This section must be completed if VPH monitoring is used to perform leak detection monitoring. System Type (Mark all that apply.) ❑X Vacuum ❑ Pressure ❑ Hydrostatic Sensor ID Component(S) Monitored By This Sensor Sensor Functionality Interstitial Communication Test Test ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail How was interstitial communication verified? ❑X Simulated Leak at Far Ends of the Interstitial Space ❑ Visual Inspection ❑ Other Describe the method In section XV below. ❑ Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? ❑X Yes ❑ No (Describe the reason in section XV below.) For any answer of "Fail " above, describe in Section XV how and when these issues were or will be corrected. XV. COMMENTS = 4 ' _. V31, r EPA9T AEN GPH = Gaflons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = VacuumtPressure/Hydrostatic, ID = Identification