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Monitoring System Certification-Page 3 of 3 Site Address: 1100 S. Main St Date of Testing/Servicing: 6122/11 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. Complete the folio Ing 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 ❑ No* Were all probes reinstalled properly? ❑ Yes 1 ❑ No* I 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 follo Ing checklist: ❑ 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: ❑ 3 g.p.h.(1 ); ❑ 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 ❑ No* For mechanical LLD's,does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLD's,does the turbine automatically shut off if the LLD detects a leak? ❑ N/A ❑ Yes ❑ 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? ❑ Yes ❑ No* For electronic LLD's,have all accessible wiring connections been visually inspected? ❑ N/A ❑ Yes ❑ No* I 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: LLD's not tested