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04/16/2004 10:59 12093651 3 TANKNOLOGY PAGE 04 <br /> Monitoring System Certification <br /> Site Address: 2905W. BENJAMIN HOLT Date of Testing/ServIew. 03/29/2004 <br /> 21-5 <br /> D. Results of Testing/Servicing <br /> Software Version Installed: 120,02 <br /> Complete the following chocklist: <br /> Yes No' Is the audible alarm operational? <br /> Yet L]No- Is the visual alarm operational? <br /> ns -L:w Were all sensors visually inspected,functionally tested,and confirmed operational? <br /> RX Y-- [I No Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not <br /> interfere with their proper operation? <br /> Yes No Lj NIA If alarms are relayed to a remote monitoring station,Is all communications equipment(e.g.modem)operational? <br /> For pressurized piping systems,does the turbine aUtOrnatiC211y shut down if the piping secondary containment <br /> 0 Yea [:]No- Lj N/A monitoring system detects a leak,falls to operate,or is electrically disconnected?If yes:which sensors Initiate positive <br /> shut-down?(check all that apply) E] Sump/Trench Sensors; Z Dispenser Containment Sensors, <br /> Did you confirm positive shut-down due to leaks and sensor failure/dIsconnaction7 L@ yes [j No <br /> Yos [-]No' NIA For tank systems that utilize the monitoring system as the primary tank overfill warning device(i.e.,no mechanical <br /> overflil prevention valve is Installed),is the overfill warning alarm visible and audible at the tank fill polnts(s)and operating <br /> properly? If so,at what percent of tank capacity dmo the alarm trigger? y2_ <br /> n Yes- ®No Was any monitoring equipment replaced?If yes,IdentlPy specific sensors,probes,or other equipment replaced and list the <br /> manufacturer name and model for all replaemeatRarts In Section 17,below, <br /> r_1 Yes' Ir Exi,NO Was liquid found inside any secondary containment systems designed as dry systems?(check all that apply) []Product: <br /> 11 Water. If yes,describe causes in Section E,below, <br /> Yes n No- Was monitoring system set-up reviewed to ensure proper settings?Attach set-up reports,If applicable. <br /> Yes r7 No Is all monitoring aquipment operational par manufacturers'specificatlons? <br /> In Section E below,describe,how and when these doficiances were or will be corrected. <br /> E. Comments: <br /> Page 2 of 3 Based on CA form dated 03101 <br />