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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page a of s XII. 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? ® ❑ ❑ For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? ❑ 1 ❑ 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? ® ❑ ❑ For an 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 Functionality Interstitial Communication Sensor ID Component(s) Monitored by this Sensor Test Test ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ 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 ❑ Fall How was Interstitial communication verified? ❑ Simulated leak at far ends of the interstitial space. [I 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 an answer of "FAIL" above describe in section XV how and when these Issues were or will be corrected. XV. COMMENTS MOM a r3arkwm nor Fw it Y a Wit N a Nn N4 a N& 2r"trmhla %mm a Van 11 cntprom jrp i4vrf, %wafir. in kfonlrfirafinn