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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) <br /> XVI. LINE LEAK DETECTOR TESTING <br /> r Check this box if line leak detectors (LLD) are NOT installed. (Do not complete this section.) Y N NA <br /> This section must be completed if LLDs are installed. <br /> Was a leak simulated to verify LLD performance? r r r <br /> Check all that apply.)Simulated leak rate verified: P-1 3 GPH r 1.1 GPH r 0.2 GPH <br /> Was the testing apparatus properly calibrated? 1 r r <br /> For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? r r r <br /> For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected? r r r <br /> For electronic LLDs, does the turbine automatically shut off when a leak is detected? r r 1170 <br /> For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? r r ry—O <br /> For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? r r r <br /> For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks? r r r <br /> Were all items on the equipment manufacturer's maintenance checklist completed? r r r <br /> Were all LLDs confirmed operational within regulatory requirements? I✓ r r <br /> For any answer of"N"above. describe in section X111 how and when these issues were or will be corrected. <br /> XIII. COMMENTS <br /> XIV. VACUUM/PRESSUREI HYDROSTATIC MONITORING EQUIPMENT TESTING <br /> 170 Check this box if VPH monitoring is NOT used. (Do not complete this section.) <br /> This section must be completed if VPH monitoring is used to perform leak detection monitoring. <br /> S stem Type Mark all that apply.) r Vacuum r Pressure r Hydrostatic <br /> Sensor ID Component(s) Monitored by this Sensor Sensor Functionality Interstitial Communication <br /> Test Test <br /> F Pass r Fail r Pass r Fail <br /> r Pass r Fail r Pass r Fail <br /> r Pass r Fail r Pass r Fail <br /> r Pass r Fail r Pass r Fail <br /> F Pass r Fail r Pass r Fail <br /> r Pass r Fail r Pass r Fail <br /> r Pass r Fail r Pass r Fail <br /> r Pass r Fail r Pass r Fail <br /> r Pass r Fail r Pass r Fail <br /> r Pass r Fail r Pass r Fail <br /> r Pass r Fail r Pass r Fail <br /> r Pass r Fail r Pass r Fail <br /> r Simulated leak at far ends of the interstitial space. r Visual Inspection <br /> How was interstitial communication verified? F Other Describe the method in section XV below. r Gauge <br /> Was the vacuum or pressure restored to operating levels in all interstitial spaces? r Yes r No (Describe the reason in section XV below.) <br /> For any answer of"N"above, describe in section X111 how and when these issues were or will be corrected. <br /> XV. COMMENTS <br /> GPH =Gallons per hour, Y=Yes, N = No, NA= Not applicable, VPH =Vacuum/Pressure/Hydrostatic, ID =Identification <br />