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Mntiitming System Certification-Page 3 of 3 <br /> Site Address. 6425 N. Pacific Ave. @ Central Ct. Date ofTeoting/Servieing: 4/20/04 <br /> F. in,Tank Ganging/MR Equipment: ® Check this box if tank gauging is used only for inventory control. <br /> ❑ Check this box if no tank gauging or SIR equipment is installed. <br /> This section must be complpled if in-tank gauging equipment is used to perForm leak detection monitoring. <br /> Complete tl?e following checklist*. <br /> C Yes o No* Has all input wiring been inspected for proper entry and termination.. including testing for ground faults? <br /> 0 Yes C No* Were all tack gauging probes visually inspected for damage and residue buildup? <br /> ❑Yes 0 No* Was accuracy of system product level readings tested? <br /> C Yes C No* Was accuracy of system water level readings tested? <br /> 0 Yes C No* Were all probes reinstalled properly'? <br /> C Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed'? <br /> *in Section 14 below,describe how and when these deficiencies were or will be corrected. <br /> r- i.inN i.Pak Iletacttirs(I.I.fl): ❑ Cherk this box if T.T.Ws are nor installed. <br /> Cont fete the following checklist: <br /> 0 Yes ❑ No* For equipment start-up or annual equipment certification was a leak simulated to verify LLD performance? <br /> C N/A (Check all rhar apply) Simulated leak reate: K 3 g.p.h.(L); C 0.1 g.p.h.(2.): C 0.2 g.p.h.(2.). <br /> Notes: 1. Required for equipment start-up certification and annual certification. <br /> 2. Unless mandated bZ local agency,certification required only for electronic LLD start-up. <br /> 10 Yes ❑ No* Were all LLD's confirmed operational and accurate within regulatory requirements? <br /> ®Yes C No* Was the testing apparatus properly calibrated? <br /> ❑Yes ❑ No* For mechanical LLD's,does the LLD restrict product flow if it detects a leak'? <br /> a N/A <br /> a Yes 0 No* For electronic LLD's,does the turbine automatically shut off if the LLD detects a leak'? <br /> C N/A <br /> 3 Yes 0 No* For electronic LLD's,does the turbine automatically shut off if any portion of the monitoring system is disabled <br /> C N/A or disconnected? <br /> Go Yes 0 No* for electronic L1-D's,docs the turbine automatically shut off it any portion of the monitoring system <br /> C N/A malfitnctions or fails a test? <br /> M Yee n Nn* For dertrnnir.T.t.T)'c,have all acressible wiring connections been visually inspected? <br /> 0NA <br /> is Yes 0 No* I Were all items on the equipment manufacturer's maintenance checklist com leted? <br /> *In Section 11 below, describe how and when these deficiencies were or will be corrected. <br /> H. Comments: <br /> L0 3E)Vd ONI SSS 9ET0IL680V 99:91 V00Z/0Z/90 <br />