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❑ Yes <br />❑ <br />F. In -Tank Gauging f SIR Equipment: ® Check this box If tank gauging Is used only for Inventory control. <br />❑ 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 perform leak detection monitoring. <br />❑ <br />Complete the follo orbig checklist: <br />Simulated leak rate: ❑ 3 g.p.h.; ❑ 0.1 g.p.h; ❑ 0.2 g.p.h. <br />❑Yes [I No- Has all input wiring bean in for proper entry and termination, including testing for ground fa <br />° `� "" <br />No' <br />a <br />D <br />❑ Yes ❑ Nb" Were all tank gauging probes visually Inspected for damage and residue buildup? <br />❑ <br />No* <br />Was tine testing apparatus properly calibrate? <br />❑ Yes ❑ No' Was accuracy of system product level readings tested? <br />❑ <br />❑ Yes ❑ Nlo° Was accuracy of system Water level readings tested? <br />2017 <br />❑ Yea ❑ No" Were all probes reinstalled properly? <br />❑ <br />❑ Yes ❑ No° Were all items ter the equipment manufacturers maintenance checklist oompleted? <br />e @fid% 9 9 LT <br />In Section H. belay, describe how and when these deficencles were or will be correcte& <br />L r PA gI -F fllj <br />Ne <br />i T- <br />U na Leak Detectors (LLD): ® Check this box If LLDs are not installed. <br />❑ <br />r`.eeeenleMn Nee hellnudnn e.hawiraat•• <br />❑ Yes <br />❑ <br />No* <br />For equipment start-up or annual equipment certification, was a leek simulated to verity LLD performance? (Check ail that apply) <br />❑ <br />N/A <br />Simulated leak rate: ❑ 3 g.p.h.; ❑ 0.1 g.p.h; ❑ 0.2 g.p.h. <br />❑ Yes <br />❑ <br />No' <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />❑ Yes <br />❑ <br />No* <br />Was tine testing apparatus properly calibrate? <br />❑ Yens <br />❑ <br />No" <br />For mechanical LLDs, does the LLD restrict product flow if it deters a leak? <br />❑ <br />WA <br />❑ Yes <br />❑ <br />Ne <br />For electronic LLD9, does the turbine automatically shut off If the LLD dem a leak? <br />❑ <br />WA <br />❑ Yea <br />❑ <br />Ne <br />For electronic LLDs, does the turbine automatically shut off If any portion of the monitoring system is disabled or disconnected? <br />❑ <br />WA <br />❑ Yes <br />❑ <br />No* <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? <br />❑ <br />WA <br />❑ Yes <br />❑ <br />No" <br />For electronle LLDs, have all accessible whnng c o nne ctbns been visually Inspected? <br />❑ <br />WA <br />❑ Yea <br />❑ <br />No* <br />I Were all items on the equipment menufacturer's maintenance checklist completed? <br />H. Comments: LINE TEST DONE <br />GENERATOR FOR HOSPITAL — NO LD <br />Monitoring System Certification Page 3 of 4 2/21107 <br />