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F. in -Tank Gauging l SIR Equipment: ® Check this box If tank gauging is used only for inventory control. <br />❑ Clic this box if no tank gauging or SIR equipment Is Installed. <br />This section must be completed N In -tank gauging equipment Is used to perform leak detection monitoring. <br />Complete the following checklist: <br />161 0 1 111— <br />❑ Yes ❑ No` Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />❑ Yes ❑ No" Were all tank gauging probes visually Inspected for damage and residue buildup? SEE <br />1 <br />❑ Yes ❑ No` Was accuracy or system product level readings tested? <br />❑ Yes ❑ No` Was accuracy of system water level readings tested? 1 <br />Yes ❑ No` Were al probes reinstalled properly? <br />❑ Yes ❑ No` Were al 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 />Lina Leak Detectors (LLD): ® Check this box If LLDs are not installed. <br />----- ---------------- <br />❑ Yes <br />❑ No` <br />For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? (Check all UW apply) <br />® WA <br />Simulated leak rate: ❑ 3 g.p.h.; ❑ 0.1 g.p.h; ❑ 0.2 g.p.h. <br />❑ Yes <br />❑ No` <br />Were all L Ds confirmed operational and accurate within regulatory requirements? <br />❑ Yes <br />❑ No` <br />Was the testing apparatus properly calibrated? <br />❑ Yes <br />❑ NV <br />For mechanical LLDs, does the LLD restrict product flow If it detects a leak? <br />® N/A <br />❑ Yes <br />❑ No' <br />For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? <br />® WA <br />❑ Yes <br />❑ No` <br />For electronic LLDs, does the turbine automatically shut off if any portion of the nonitoring system Is disabled or dlaconnected? <br />® NA <br />❑ Yes <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 />® NA <br />❑ Yes <br />❑ ho" <br />For electronic LLDs, have an accessible wiring connections been visually inspected? <br />® NA <br />❑ Yes <br />❑ No` <br />Were all items on the equipment manufacturers maintenance checklist completed? <br />In Section H, below, describe how and when these deficiencies were or slim to corrected. <br />H. Comments: GENERATOR FOR A HOSPITAL NO LEAK DEFECTOR ALLOWED <br />Monitoring System Certification Page 3 of 4 2/21/07 <br />