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NW <br /> Monitore System Cerrtifieation <br /> F. In.-Tank Ganging f SIR EgttipmeDt: 21 CA=k this box if tank gauging is used only for inventory control. <br /> ❑ Check this box if no tank gauging or SIR egaiptr:ent is installed <br /> This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. <br /> Complete the ronowie+g£heeklist. <br /> r0y�ccss <br /> ❑ No* Has all Input wiring been insp%ted for proper entry and termination,including testing far ground faualts? <br /> 0 Nv* Were all tank gnu ging pubes visually ins for damage and residue buildup? <br /> ® No* Was accuracy of system product level readings tested7 <br /> Q No* Was wcuracy of system water level readings tested? <br /> ❑ No* Were all pmbes reinstalled property?p Nat* Were all items on the equipmentmewfutuumst's to ' nee checklist cotnpleted? <br /> *7a thea Section H,below,describe how and when these deficiencies were or wiU be co,rseeled. <br /> G. bine Lvak De ors(1,LD): ❑ Check this box if LLDs arc not installed. <br /> Cam lets the rotlowIn checklist: <br /> FOY" <br /> Yes ® Ne►' For esquiprne"t start-up or annual equipment Qertifieation, was a teak simulated to verify LLD perforaiianae7 <br /> ❑ N/A (Check alt them apply) Simulated leak rate: 19 3 g.p.h.; ❑61.1 g.p.h; ❑0.2 g.p.h. <br /> ❑ Not- Were all Ups confirmed operational and accurate within regulatory requi ? <br /> ❑ No* Was the testing apparatus properly calibrated? <br /> ❑ No* Far mechanical LLDs,docs the LLD rstrict prodm-t flow if it detests m leak? <br /> ❑ N!A <br /> 0 No* For electronic LLDs,does the tuurbine auto y shut off'ifft LLD detects a leak? <br /> ® NIA <br /> [j No* Fen~electronic LLDs, does the turbine automatiealiy strut off'if any portion of the monitoring system is disabled <br /> ® NIA or discannectc& <br /> ❑ No* For el c LLD%does the turbine automaticaIly shut off`if any portion of the monitoring system msifunC60M <br /> ® N/A or flails a test? <br /> LY ® No* For electronic LLD9,have all accessible wiring connectionsbeen visually inspected? <br /> ® NIA C No* �.Were all items on the equipment manufaetuser's maintenance checklist completed? <br /> *in the Section H'below,describe how and when these defii£iemeies were or will be corrected. <br /> H, Comments: <br /> Page 3 of 4 ENVIRONMENTAA HEALTH <br /> DEPARTMENT <br /> 1?'d 09699V960Z uaneloaled 9RS11821 8£Z:ZO V 1,6Z 6ny <br />