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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) XII . LINE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors (LLD) are NOT installed . (Do not complete this section.) FEI 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 : El3 GPH E] 0. 1 GPH El0. 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? ❑ ❑ ❑ 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? ❑ ❑ 1:1For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? El 1:1 1:1For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? F] ❑ El Were all items on the equipment manufacturer's maintenance checklist completed ? El ❑ 1:1Were all LLDs confirmed operational within regulatory requirements? El El ❑ For any answer of "M' above, describe in Section Xlll how and when these issues were or will be corrected. XIII . COMMENTS Mechanical Electronic monitoring certification XIV. VACUUM / PRESSURE / HYDROSTATIC MONITORING EQUIPMENT TESTING ❑ X 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 By This Sensor Sensor Functionality Interstitial Communication Test Test ❑ 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 ❑ Fail ❑ Pass ❑ Fail [:] Pass ❑ Fail ❑ Pass ❑ Fail How 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 10 L E ENV "x ;, 4_ . i € �E GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification UN-107 www. unidoes.org 5/6 - Rev. 10/01 /18