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Aug. 1$. 2016 10: 19AM Doee Pump Co No- 5143 P. 5 <br /> Monitoring System certification <br /> F. In-Tank Gauging/SIR Equipment: 0 Check ft box if tank gauging is used only 1pmen s UV't <br /> 0 Check this box if no tank gauging or SIR eqtu �mcae - <br /> This section must be completed if in-twik gauging equipment is used to perform leak detection ra"Ahl. 2016 <br /> Complete the following checklist: <br /> 0 Yes 0 No* Ws all input wiring been inspected for proper entry and termination,including testing for ground faults? <br /> El Yes [I No* Were all tank gauging probes visually inspected for damage and residue buildup? <br /> El Yes 0 No* Was accuracy of system product level readings tested? <br /> ❑—Yes 0 No* Was accuracy of system water level readings tested? <br /> • Yes [I No* Were all probes reinstalled properly? <br /> • Yes 0 No* Were all items on the equipment manufacturer's maintenance checklist completed? <br /> *In Section H,below,describe how and when these deficiencies were or will be corrected. <br /> G. Line Leak Detectors (LLD): 0 Check this box if LLDs are not installed. <br /> Complete ffie fallowi ag checklist; <br /> 1) <br /> 0 Yes 0 No* For equipment start-up or annual equipment certification, was a leak simulated to verify LL performance? <br /> 0 NIA (Check all that apply) Simulated leak rate: D 3 g.p.h-; 13 0.1 g.p.h; [10.2 g.pAL <br /> 0 Yes El No* Were all LUDs confinned operational and accurate within regulatory requirements? <br /> [I Yes 0 No* Was the testing apparatus properly calibrated? <br /> 0 Yes 0 NO For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> D N/A <br /> 0 Yes 0 No* For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? <br /> 0 N/A <br /> 0 Yes 0 No* For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled <br /> El N/A or disconnected? <br /> (3 Yes (j NO For electronic LLD.9,does the turbine automatically shut off if any portion of the monitoring system malfunctions <br /> [3 N/A or fails a test? <br /> n Yes 0 No* For electronic LLDs,have all accessible wiring connections been visually inspected? <br /> 0 N/A <br /> 0 Yes 0 No* I Were all items on the equipment manufacturer's maintenance checklist completed? <br /> In$eetlon 9,below,describe how and when these deficiencies were or will be corrected. <br /> R. Comments: <br /> Page 3 of 4 <br /> C/N'-036-516 www.muldoes.org Rev.01/17108 <br />