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RECEIVED Monitoring System Certification-Page 3 of 3 DEC 12 2014 Site Address: 1987 W. 11th St. Date of Testinu//Servicin 11/13/14 1ENVIRONME HEAL-- F. In-Tank Gauging/SIR Equipment: ® Check this box if tPURWI �is useabnly for inventory control. ❑ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Complete the folio Ing checklist: ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination,including testing for ground faults`? ❑ Yes D No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of system product level readings tested? 0 Yes ❑ No* Was accuracy of system water level readings tested? ❑ Yes ❑ No* Were all probes reinstalled property? ❑ Yes O No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below,describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors(LLD): Check this box if LLD's are not installed. Com tete the folio Ing checklist: D Yes ❑ No* For equipment start-up or annual equipment certification was a leak simulated to verify LLD performance? O N/A (Check all that apply) Simulated leak rate: ❑ 3 g.p.h.(1.); 0 0.1 g.p.h.(2); ❑ 0.2 g.p.h.(2.). Notes: 1. Required for equipment start-up certification Od annual certification. 2. Unless mandated by local agency,certification required only for electronic LLD start-up. ❑ Yes ❑ No* Were all LLD's confirmed operational and accurate within regulatory requirements? ❑ Yes 0 No* Was the testing apparatus properly calibrated? ❑ Yes 0 No* For mechanical LLD's,does the LLD restrict product flow if it detects a leak? 0 N/A ❑ Yes O No* For electronic LLD's,does the turbine automatically shut off if the LLD detects a leak? 0 N/A ❑ Yes 0 No* For electronic LLD's,does the turbine automatically shut off if any portion of the monitoring system is disabled 0 N/A or disconnected? 0 Yes ❑ No* For electronic LLD's,does the turbine automatically shut off if any portion of the monitoring system ❑ NIA malfunctions or fails a test? ❑ Yes D No For electronic LLD's,have all accessible wiring connections been visually inspected? 0 N/A ❑ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? *In Section H below,describe how and when these deficiencies were or will be corrected. H. Comments: PLLD's not required to be tested.