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1,16 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) X11. LINE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors (LLD) are NOT installed. (Do not complete this section.) Y N NA This section must be completed If LLDs are Installed. Was a leak simulated to verify LLD performance? ® ❑ ❑ Check all that apply.) Simulated leak rate verified: ® 3 GPH ❑ 0. 1 GPH ❑ 0.2 GPH Was the testing apparatus properly calibrated? 1@ ❑ ❑ For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? ❑ ❑ For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected? ® ❑ ❑ For electronic LLDs, does the turbine automatically shut off when a leak is detected? ® ❑ ❑ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ® ❑ ❑ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ® ❑ ❑ For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks? ® ❑ ❑ Were all items on the equipment manufacturer's maintenance checklist completed? ® ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? 1 ® ❑ ❑ For any answer of "N" above describe In section X111 how and when these issues were or will be corrected. XIII. COMMENTS XIV. VACUUM / PRESSURE/ HYDROSTATIC MONITORING EQUIPMENT TESTING ® Check this box if VPH monitoring is NOT used . (Do not complete this section.) This section must be completed If VPH monitoring Is used to perform leak detection monitoring. System Type (Mark all that apply.) ❑ Vacuum ❑ Pressure ❑ Hydrostatic Sensor ID Component(s) Monitored b this Sensor Sensor Functionality Interstitial Communication Y Test Test ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fait ❑ Pass ❑ Fail ❑ Pass ❑ Fail Haw was interstitial communication verified? ❑ Simulated leak at far ends of the interstitial space. Visual Inspection ❑ Other (Describe the method In section XV below.) ❑ Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? ® Yes ❑ No (Describe the reason In section XV below.) For any answer of "FAIL" above describe in section XV how and when these Issues were or will be corrected. XV. COMMENTS f;PH = falku�c ror Fuu it V = Yae N = Nn NO = NM aruilrrahrr+ VPN = Van a onlprwcc� irNHvrimalaHr. Irl = kiwntifiratrrwt