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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) X114 LINE LEAK DETECTOR TESTING FCheck oxif 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? ❑ ❑ ❑ (Check all that apply.) Simulated leak rate verified : ❑X 3 GPH ❑ 0. 1 GPH ❑ 0.2 GPH Was the testing apparatus properly calibrated ? ❑X ❑ ❑ For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? ❑ ❑ X❑ 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 ? ❑ ❑ ❑X For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected ? ❑ ❑ X❑ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ ❑ XQ 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? ❑X ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? Q I ❑ I ❑ 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 f HYDROSTATIC MONITORING EQUIPMENT TESTING ❑X 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 ❑ Hydrostatic Sensor ID Component(S) Monitored By This Sensor Sensor Functionality Interstitial Communication Test Test ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail How was interstitial communication verified ? ❑ Simulated Leak at Far Ends of the Interstitial Space ❑ Visual Inspection ❑ 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 GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification UN -107 www.unidocs.org 516 - Rev. 10/01 /18