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RECEIVED <br />,1,'l 25 2013 <br />F. In -Tank Gauging / SIR Equipment: 17 Check this box if tank gauging is used only for inventory control. <br />r Check this box if no tank gauging or SIR L' i G IMOM 4 ENTAL <br />This section must be completed if in -tank gauging equipment is used to perform leak detection monitoring. HEALTH DEPARTMENT <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 />• Yes <br />r No* <br />Were all tank gauging probes visually inspected for damage and residue buildup? <br />• Yes <br />r No* <br />Was accuracy of system product level readings tested? <br />• Yes <br />r No* <br />Was accuracy of system water level readings tested? <br />• Yes <br />No* <br />lNere all probes reinstalled properly? <br />• Yes <br />r No* <br />ere all items on the equipment manufacturer's maintenance checklist completed? <br />* In the Section H, below, describe how and when these deficiencies were or will be corrected. <br />G. Line Leak Detectors (LLD): r Check this box if LLDs are not installed. <br />Complete the following checklist: <br />• Yes <br />No* <br />For equipment start-up or annual equipment certification was a leak simulated to verify LLD performance? (Check all that <br />apply) Simulated leak rate: r 3 g.p.h.; r 0.1 g.p.h; I 0.2 g.p.h. <br />N/A <br />• Yes <br />No* <br />Were all LLDs confirmed 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 or disconnected? <br />• N/A <br />• Yes <br />No* <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? <br />l: N/A <br />Yes <br />No* <br />For electronic LLDs, have all accessible wiring connections been visually inspected? <br />• N/A <br />• Yesr <br />No* <br />Were all items on the equipment manufacturer's maintenance checklist completed? <br />* In the Section H, below, describe how and when these deficiencies were or will be corrected. <br />H. Comments: <br />Page 3 of 3 12/07 <br />