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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 4 of 6) Ville MONITORING SYSTEM AND PROGRAMMING This section must be completed if a monitoring panel is used to perform leak detection monitoring. Y N NA Are the visual and audible alarms operational? 0 ❑ I ❑ Were all sensors visually inspected for kinks and breaks in the cables and for residual buildup to ensure that floats move freely, N ❑ ❑ functionally tested , and confirmed operational? Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with n ❑ ❑ their proper operation? Was monitoring system set-up reviewed to ensure proper settings? Q ❑ ❑ Was the monitoring panel's backup battery visually inspected , functionally tested , and confirmed operational? ❑ ❑ Does the flow of fuel stop at the dispenser if a leak is detected in the under-dispenser containment? Q ❑ ❑ Does the turbine automatically shut down if the piping secondary containment monitoring system fails to operate or is electrically n ❑ ❑ disconnected ? Does the turbine automatically shut down if the piping secondary containment monitoring system detects a leak? FRI ❑ ❑ Which sensors initiate positive shut down? (Check all that apply.) ❑X Sump Q Under-Dispenser Containment If alarms are relayed to a remote monitoring station , is all communications equipment (e.g . , modem) operational? 1:1 ❑ Q For any answer of "N " above, describe in Section IX how and when these deficiencies were or will be corrected. Ilk COMMENTS X. IN-TANK GAUGING TESTING ❑ Check this box if tank gauging is used only for inventory control. (Do not complete this section.) ❑ Check this box if NO tank gauging equipment is installed . (Do not complete this section.) Y IN NA This section must be completed if in-tank gauging is used to perform leak detection monitoring. Has all input wiring been inspected for kinks and breaks in the cables and for proper entry and termination , including testing for ❑ ❑ ❑ round faults? Were all in-tank gauging probes visually inspected for damage and residue buildup to ensure that floats move freely, functionally ❑ ❑ ❑ tested , and confirmed operational? Was accuracy of system's product level readings tested? ❑ ❑ ❑ Was accuracy of system's water level readings tested? ❑ ❑ ❑ Were all probes reinstalled properly? ❑ ❑ ❑ Were all items on the equipment manufacturer's maintenance checklist completed? ❑ I ❑ I ❑ For any answer of "N" above, describe in Section XI how and when these deficiencies were or will be corrected. XI . COMMENTS Overfill Prevention Equipment testing is done Tri-Annually. i Y = Yes, N = No, NA = Not Applicable UN407 www.unidocs .org 4/6 - Rev. 10/01 /18 c I r I