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Monitoring System Certification - Page 3 of 3 Site Address: 1987 W. 11th St. F. In - Tank Gauging / SIR Equipment: I�ECtivt� D�� def 444 vicing: 6/18116 ❑ Check this box if tank gauginis u e' 4 g only 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 following checklist: ® Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? ® Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ® Yes ❑ No* Was accuracy of system product level readings tested? ® Yes ❑ No* Was accuracy of system water level readings tested? ® Yes 1 ❑ No* Were all probes reinstalled properly? ® Yes 1 ❑ 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. Complete the following checklist: 0 Yes ❑ No* For equipment start-up or annual equipment certification was a leak simulated to verify LLD performance'? ❑ N/A (Check all that apply) Simulated leak rate: IN 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 and 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 ❑ 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? ® N/A 0 Yes ❑ No* For electronic LLD's, does the turbine automatically shut off if the LLD detects a leak? 0 N/A 0 Yes 0 No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system is disabled ❑ N/A or disconnected? ® Yes ❑ No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system ❑ N/A malfunctions or fails a test? 0 Yes ❑ No* For electronic LLD's, have all accessible wiring connections been visually inspected? N/ EMA❑ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below. describe how and when these deficiencies were nr will he corrected_ H. Comments: