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Site Address: X( I'> ;. L �e .4th 57 %rc -=i< L4<rcf� Date of Testing/Servicing: `71Z//0'( F. In-Tank Gauging/SIR Equipment: ❑ Check this box if tank gauging is used 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_ Com Tete the following checklist: 2"�es ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? es ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? [1,1fes ❑ Ivo* Was accuracy of system product level readings tested? ❑jYes ❑ No* Was accuracy of system water level readings tested? p`Yes ❑ No* Were all probes reinstalled properly? 1� es ❑ 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- Complete nstalled.Com ete the foil owing checklist: [KYes ❑ No* For equipment start-up or annual equipment ceoffication, was a leak simulated to verify LLD performance? ❑ N/A (Check all that apply) Simulated leak rate: g.p.h.'; ❑ 0.1 g.p.h.Z; ❑ 02 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. Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? ONY es ❑ No* Was the testing apparatus properly calibrated? lis ❑ No* For mechanical LLDs,does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ NN For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? C N/A ❑ Yes ❑ No* For electronic LLDs,does the turbine automatically shut o$'if any portion of the monitoring system is disabled ET-N/A or disconnected? ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system ©'NN/A malfunctions or fails a test? ❑ Yes ❑ No* For electronic LLDs,have all accessible wiring connections been visually inspected? C�N/A 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. H. Comments: Page 3 of 3 03/01