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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) XII . LINE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors (LLD) are NOT installed . (Do not complete this section.) Y N NA This section must be completed if LLDs are installed. Was a leak simulated to verify LLD performance? RX El 1:1(Check all that apply.) Simulated leak rate verified : 0 3 GPH El 0. 1 GPH El 0.2 GPH Was the testing apparatus properly calibrated ? M ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected? ❑ ❑ N For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected? ❑X ❑ ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected? ❑ ❑ Q For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑ ❑ I0 For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ ❑ Q For electronic LLDs , have all accessible wiring connections been visually Inspected for kinks and breaks? ❑ ❑ X❑ Were all items on the equipment manufacturer's maintenance checklist completed? 0 ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? 9 ❑ ❑ For any answer of "N" above, describe in Section Xlll how and when these issues were or will be corrected. XIII . COMMENTS XIV. VACUUM ! PRESSURE / HYDROSTATIC MONITORING EQUIPMENT TESTING ❑ Check this box if VPH monitoring is NOT used . (Do not complete this section.) This section must be completed if VPH monitoring is used to perform leak detection monitoring. System Type (Mark all that apply.) ❑ Vacuum ❑ Pressure ❑X Hydrostatic SSensor Functionality Interstitial Communication ensor ID Component(S) Monitored By This Sensor Test Test L1 420 Sensor Annular UST ❑X Pass ❑ Fail ❑ Pass ❑ Fail L2 208 STP Sensor ❑X Pass ❑ Fail ❑ Pass ❑ Fail L3 208Transition Sump ❑X Pass ❑ Fall I ❑ Pass ❑ Fail L4 208 Reek ( UDC) ❑X Pass ❑ Fail ❑ Pass ❑ Fail L5 420 Sensor Annular AST Q Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail a ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fait ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fait ❑ Pass ❑ Fail ❑ Pass ❑ Fail How was interstitial communication verified? ❑ Simulated Leak at Far Ends of the Interstitial Space ❑ visual Inspection ❑X Other Describe the method in section XV below.) Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? ❑ Yes ❑ No (Describe the reason In section XV below.) For any answer of "Fail' above, describe In Section XV how and when these Issues were or will be corrected. XV. COMMENTS Ll - L5 liquid sensor dipped in water to verify functionality GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = VacuumiPressure/Hydrostatic, ID = Identification