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E <br />11 <br />F. In -Tank Gauging / SIR Equipment: S Check this box if tank gauging is used only for inventory control. <br />0 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 <br />r7l Yes <br />0 Yes <br />0 Yes <br />_ff Yes <br />_t5 <br />Yes <br />I ==� <br />* In the Section Ii, below, describe how and when these deficiencies were or will be corrected - <br />G. Line Leak Detectors (LLD): n Check this box if LLDs are not installed. <br />I <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />Corn lete <br />2E&�� <br />Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />0 <br />No* <br />Were all tank gauging probes visually inspected foi damage and residue buildup? <br />gauging <br />[I No* <br />0 No* <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />Was accuracy of system product level readings tested? <br />❑ No* <br />E I No* <br />0 <br />For mechanical LLDs, does the LLD restrict product flow if it detects a leak? <br />Was accuracy of system water level readings tested? E Ej <br />G <br />Were all probes reinstalled properly?❑ <br />No* <br />❑E <br />[I No* <br />No* <br />completed? IJLL U I LUU <br />Were all items on the equipment manufacturer's maintenance checklist coo I <br />I ==� <br />* In the Section Ii, below, describe how and when these deficiencies were or will be corrected - <br />G. Line Leak Detectors (LLD): n Check this box if LLDs are not installed. <br />I <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />Corn lete <br />2E&�� <br />the fo o <br />in& checklist: <br />For equipment start-up or annual equipment certification, w as a leak simulated to verify LLD performance? <br />(Check, all that apply) Simulated leak rate: CD3 g.p.h.: 0 0.1 g.p.h -, 0 0.2 g.p.h. <br />0 Yes <br />[I No* <br />El N/A <br />0 Yes <br />0 No* <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />Was the testing apparatus properly calibrated? <br />[D yes <br />E I No* <br />0 <br />For mechanical LLDs, does the LLD restrict product flow if it detects a leak? <br />Yes <br />S n yes <br />IF❑ <br />0 0* <br />C] NO* <br />El N/A <br />C] Yes <br />E] No* <br />Z N/A <br />For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? <br />off if any portion of the monitoring system is disabled <br />For electronic LLDs, does the turbine automatically shut o <br />or disconnected) <br />0 Yes <br />El No* <br />ED N/A <br />e automatically shut off if any portion of the monitoring system <br />For electronic LLDs, does the turbine <br />malfunctions or fails a test? <br />[01 Yes <br />No* <br />0 N/A <br />For electronic LLDs, have all accessible wiring connections been visually inspected? <br />Es[01 <br />0 Yes <br />El No* <br />[D N/A <br />0 <br />Were all items on the equipment manufacturer's maintenance checklist completed? <br />R Yes <br />❑ No * <br />* In the Section K, below, aescriDe now unu wilull kllr.5c U., ........ <br />fffl1'� <br />Monitoring Certification Test Report 3 of 4 <br />