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itoring System Certification 10 <br /> Site Address: 2705 COUNTRY CLUB BLVD Date of Testing/Service: 05/11/2005 <br /> Q-C DIS#1-2& DIS#3-4 <br /> F. In-Tank Gauging/SIR Equipment Q Check this box if tank gauging is used only for inventory control. <br /> ❑ 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 monitoring. <br /> Complete the following checklist: <br /> 0 Yes ❑Nos Has all input wiring been inspected for proper entry and termination,including testing for ground faults? <br /> 0 Yes ❑No` Were all tank gauging probes visually inspected for damage and residue buildup? <br /> I Yes ❑No` Was accuracy of system product level readings tested? <br /> Q Yes ❑No° Was accuracy of system water level readings tested? <br /> FX-1 Yes ❑No• Were all probes reinstalled properly? <br /> ®Yes ❑No. Were all items on the equipment manufacturers'maintenance checklist completed? <br /> *In the Section H,below,describe how and when these deficiencies were or will be corrected. <br /> G. Line Leak Detectors (LLD) : ❑ Check this box if LLDs are not installed. <br /> Complete the following checklist: <br /> ®Yes ❑No* E]NIA <br /> For equipment start-up or annual equipment certification,was a leak simulated to verify LLD performance? <br /> (Check all that apply)Simulated leak rate: Q 3 g.p.hE]0.1 g.p.h ❑0.2 g.p.h <br /> [-X-1 Yes ❑No° Were all LLDs confirmed operational and accurate within regulatory requirements? <br /> [-Xj Yes ❑No- Was the testing apparatus properly calibrated? <br /> ❑X Yes ❑No. ❑NIA For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> ❑Yes [:]No° Q N/A For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? <br /> ❑Yes ❑No• 0 N/A For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? <br /> ❑Yes ❑No• ®N/A For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? <br /> ❑Yes ❑No* 0 NSA For electronic LLDs,have all accessible wiring connections been visually inspected? <br /> ❑Yes ❑No" Were all items on the equipment manufacturers'maintenance checklist completed? <br /> *In the Section H,below,describe how and when these deficiencies were or will be corrected. <br /> H. Comments: <br /> REGULAR UNL FILL/VAPOR SUMP HAD APPROX .5 INCHES OF WATER. REMOVED BY ON SITE PERSONAL AND PLACED IN <br /> 55 GALLON DRUM. <br /> Page 3 of 3 Based on CA form dated 03/01 <br />