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Sep, 8, 2017 8:44AM Donlee Pump Co No- 8205 P. 4 <br /> Monitoring System Certification 0 0 <br /> F. In-Tank Gauging/SIR Equipment: 19 Chock this box if tank gauging is used only for inventory control. <br /> 0 Check this box if no tank gauging or SIR equipment is installed. <br /> This section must be completed if in-tank gauging equipment is used to perf6im leak detection monitoring. <br /> Complete the following checklist: <br /> • Yes 0 No* Has all input wiring been inspected for proper entry and termination,including testing for ground faults? <br /> • Yes 0 No* Were all tank gauging probes visually inspected for damage and residue buildup? <br /> EJ Yes 0 No* Was accuracy otsystem product level readings tested? D <br /> LJ Yes L] No* . Was accuracy of system water level readings tested? <br /> - -,I-L OR 201,17 <br /> 0 Yes 0 No* Were all probes reinstalled properly? <br /> 0 Yes 0 No* Were all items on the equipment manufacturer's maintenance checklist completed? <br /> L= ENVIRONMENTAIL. HIBALTH <br /> In Section A below,describe how and when these deficiencies were or will be corrected DEPA RTMEN I <br /> G. Line Leak Detectors (LLD): (j Check this box if LLDs.are not installed. <br /> Com lets the follo ing checklist: <br /> *9 Yes (j Nox For equipment start-up or annual equipment certification, was a leak simulated to verity LLD performance? <br /> C] N/A (Check all that apply) Simulated leak rate: a3 g.p.h.; Q 0.1 g.p.h; 0 0.2 g.p.h. <br /> t9 Yes 0 No; Were all LM confirmed operational and accurate within regulatory requirements? <br /> B Yes tj No* Was the testing apparatus properly calibrated? <br /> gi Yes n No* for mechanical LLDs,does the LLD restrict product How if it detects a leak? <br /> C1 N/A <br /> [I Yes [3 No* For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? <br /> N/A <br /> El Yes 0 No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled <br /> 44 N/A or disconnected? <br /> • Yes 0 No* For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions <br /> Z N/A or fails a test? <br /> • Yes 0 No" For electronic LLDs,have all accessible wiring connections been visually inspected? <br /> N/A <br /> Yes Q No* Were all items on the equipment manufacturer's maintenance checklist completed? <br /> In Section H,below,describe how and when these dericlencies were or will be corrected. <br /> H. Comments; <br /> Page 3 of 4 <br /> UN-036—516 WV"Y'Unidoes-Org Rev.01/17108 <br />