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'Monitoring System Certification <br />Fite Address: %Df Testing/Servicing: <br />F. In -Tank Gauging/ SIR Equipment: X—Check this box if tank gauging is used only for inventory control. <br />U 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 nionitoning., <br />Complete the following checklist: <br />U,Yes U N <br />,0 1 Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />11 s 11 )Qo* Were all tank gauging probes visually inspected for damage and residue buildup? <br />U -Yes No* Was accuracy of system product level readings tested? <br />• YesNo* Was accuracy of system water level readings tested? <br />• Yesy? C) 0* Were all probes reinstalled properly? <br />U s E03NN Were all items on the equipment manufacturer's maintenance checklist completed? <br />Ilk -the Section ", below, describe how and when these deficiencies were or will be corrected. <br />G. Line Leak Detectors (LLD): El Check this box if LLDs are not installed. <br />C mplete the following checklist: <br />Yes <br />I <br />Q No* <br />Q N/A <br />For equipment start-up or annual equipmeit rtification, was a leak simulated to verify LLD performance? <br />(Check all that apply) Simulated leak rate: V3 g.p.h.; E3 0.1 g.p.h ; 0 0.2 g.p.h. <br />WYes <br />0 No* <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />AYes <br />0 No* <br />Was the testing apparatus properly calibrated? <br />11 Yes <br />E3 No* <br />For mechanical LLDs, does the LLD restrict product flow if it detects a leak? <br />Yes <br />13 No* <br />0 N/A <br />For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? <br />I <br />Yes <br />Q No* <br />(3 N/A <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled <br />or disconnected? <br />Yes <br />U No* <br />LI N/A <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system <br />malfunctions or fails a test? <br />Yes <br />Ej No* <br />Q N/A <br />For electronic LLDs, have all accessible wiring connections been visually inspected? <br />es <br />E3 No* <br />Were all items on the equipment manufacturer's maintenance checklist completed? <br />ection H. <br />below. describe [tow anti when flipto dol'iripneipeworp nr will hp enrrpofarl <br />H. Comments: <br />Page 3 of 3 05M I <br />L <br />