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Mar, 28. 2014 2.49PM Donlee Pump Co. No, 694) P. 5 <br />Monitoring System Certification <br />F. In -Tams Gauging / SIR 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 />171is section must be completed if in -tank gauging equipment is used to perform leak detection monitoring. <br />Complete the following checklist: <br />Yes <br />❑ No* <br />Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />es <br />0 No* <br />Were all tank gauging probes visually inspected for damage and residue buildup? <br />Yes <br />❑ No* <br />Was accuracy of system product level readings tested? <br />Yes <br />❑ No* <br />Was accuracy of system water level readings tested? <br />Yes <br />❑ No* <br />Were all probes reinstalled properly? <br />�ye <br />* In Section <br />d No* Were all items on the equipment manufacturer's maintenance checklist completed? <br />H. below. de-Reribe how and when these defichmeiec ware nr will ha rnrrPrtPd <br />G. Line Leak Detectors (LLD): ❑ Check this box if LLDs. are not installed. <br />rmmnlete the follnwinu rherklist! <br />❑ Yes <br />❑ No* <br />For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? <br />❑ N/A <br />(Check all that apply) Simulated leak .rate: ❑ 3 g.p h.; ❑ 0.1 g.p.h ; El 0.2 g.p.h. <br />❑ Yes <br />l-7. No* <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />❑ Yes <br />❑ No* <br />Was the testing apparatus properly calibrated? <br />l Yes <br />❑ No, <br />For mechanical LLDs, does the LLD restrict product flow if it detects a leak? <br />❑ N/A <br />❑ Yes <br />❑ No* <br />For electronic .LLDs, does the turbine automatically shut otf if the LLD detects a leak? <br />❑ N/A <br />❑ Yes <br />❑ No* <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring systm is disabled <br />❑ N/A <br />or disconnected? <br />❑ Yes <br />❑ No* <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions <br />❑ N/A <br />or fails a test? <br />❑ Yes <br />❑ No* <br />For electronic LLDs, have all accessible wiring connections been visually inspected? <br />❑ N/A <br />❑ Yes <br />❑ No* <br />Were all items on the equipment manufacturer's maintenance checklist completed? <br />x In Section 13, below, describe bow and when these deficiencies were or will be corrected. <br />H. Comments: �OZM 4 A1,4 G' </5 W/' . OA d e1 44;�_ C44 -4 <br />UN -036 - 5/6 <br />Page 3 of 4 <br />www.uuidoes.org <br />S 2014 <br />Rev. MOM <br />