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Monitoring System Certification-Page 3 of 3 Site Address; 1103S. Main St Date of Testing/Servicing: 1/19/12 F. In -Tank Gauging/SIR Equipment: N Check this box if tank gauging is used only for inventory control. ❑ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Complete the foliowin"'checklist: 0 Yes ❑ No* Has all input wiring been inspected for proper entry and termination,including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of system product level readings tested? 0 Yes ❑ No* Was accuracy of system water level readings tested? ❑ Yes ❑ probes reinstalled properly? ❑ Yes 0 No- I Were all items on the equipment manufacturer's maintenance checklist completed? *In Section H below,describe how and whenthese deficiencies were or will be corrected. G. Line Leak Detectors(LLD): ❑ Check this box if LLD's are not installed. Com lete the folio ing checklist: 3 Yes ❑ No* For equipment start-up or annual equipment certification was a leak simulated to verify LLD performance? ❑ N/A (Check all that apply) Simulated leak rate: N 3 g.p.b.(L); ❑ 0.1 g.p;h.(2.); 0 0.2 g.p.h.(2.). Notes: 1. Required for equipment start-up certification and annual certification. 2. Unless mandated by local agency,certification required only for electronic LLD start-up. M Yes 1 ❑ No* Were all LLD's confirmed operational and accurate within regulatory requirements? 0 Yes ❑ No* Was the testing apparatus properly calibrated? 13 Yes ❑ No* For mechanical LLD's,does the LLD restrict product flow if it detects a leak? C9 N/A • Yes ❑ No* For electronic LLD's,does the turbine automatically,shut off if the LLD detects a leak? ❑ N/A • Yes ❑ No* For electronic LLD's,does the turbine automatically shut off if any portion of the monitoring system is disabled ❑ N/A or disconnected? M Yes ❑ No* For electronic LLD's,does the turbine automatically shut off if any portion of the monitoring system ❑ N/A malfunctions or fails a test? 0 Yes ❑ No* For electronic LLD's,have all accessible wiring connections been visually inspected? 1 ❑ NwA I — 0 Yes I ❑ No* I Were all items on the equipment manufacturer's maintenance checklist completed? *In Section H below,describe how and when these deficiencies were or will be corrected. 11. Comments: