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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page 5 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? ® ❑ I ❑ 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 flowthrough the pipe when a leak is detected? ® ❑ 1 ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected? El F1Q 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? ❑ 1 ❑ Were all items on the equipment manufacturer's maintenance checklist completed? ® ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? ® ❑ ❑ For any answer of "N" above, describe in Section X111 how and when these issues were or will be corrected XIII . COMMENTS XIV , VACUUM I PRESSURE I 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 By This Sensor Sensor Functionality Interstitial Communication Test Test ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ 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 \Asual 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 GPH = Gallons Per Hour, Y = Yes, N = No , NA = Not Applicable, VPH = VacuumPiesswehtydrostatic, ID = Identification i i