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Mar -18. 2014 2:44PM Donlee Pump Co. <br />Monitoring System Certification <br />F. In -Tank Gauging / SYR Equipment: <br />No. 6819 P. 4 <br />❑ Check this box if tank gauging is used only for inventory control. <br />❑ Check this box if no tank gauging or S.TR equipment is installed. <br />This section must be completed if in -tank gauging equipment is used to perform leak detection monitoring. <br />Complete the following Checklist, <br />KI Yes <br />❑ No* <br />Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />es <br />❑ 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 />C7 No* <br />Was accuracy of system water level readings tested? <br />Yes <br />❑ No" <br />Were all probes reinstalled properly? <br />Yes <br />❑ No* <br />Were all .items on the equipment manufacturer's maintenance checklist completed? <br />* In Section <br />H. below. describe how and when these deficiencies were or will be corrected. <br />G. Line Leak Detectors (LLD): ❑ Check this box if LLDs are not installed. <br />C amnlete the following cherklict! <br />Q Yes <br />❑ No* <br />For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? <br />❑ NIA <br />(Check all that apply) Simulated leak rate: ❑ 3 g.p.h.; ❑ 0.1 g.p.b ; ❑ 0.2 g.p.h. <br />❑ Yes <br />❑ No* <br />Were all LLDs cottfnrm.ed operational and accurate within regulatory requirements? <br />❑ Yes <br />❑ No* <br />Was the testing apparatus properly calibrated? <br />❑ 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 off 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 system 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 />❑ Noy' <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 />* In Section H, below, describe how and when these deficiencies were or will be corrected. <br />H. Comments: �g9, �' .�S a"C . g � A 'ir <br />UIN-OM — 516 <br />Page 3 of 4 <br />www.unidomorg <br />MAR 18 2014 <br />Rev. OM7108 <br />