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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) XII. LINE LEAK DETECTOR TESTING ❑ Check this box if 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 ? Q ❑ ❑ (Check all that apply.) Simulated leak rate verified : ® 3 GPH ❑ 0 . 1 GPH ❑ 0. 2 GPH Was the testing apparatus properly calibrated? ® ❑ ❑ For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? ❑ Hc[:i Q For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected ? Q ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected? ❑ ❑ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑ ❑ I Q For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ ❑ For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? ❑ ❑ Were all items on the equipment manufacturer's maintenance checklist completed ? Q ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? Q ❑ For any answer of "N" above, describe in Section Xlll how and when these issues were or will be corrected. XIII . COMMENTS XIV, VACUUM I PRESSURE I HYDROSTATIC MONITORING EQUIPMENT TESTING Q Check this box if VPH monitoring is NOT used . (Do not complete this section.) This section must be completed if VPN 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 I ❑ 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 PerHour, Y = Yes, N = No, NA = NotApplicable, VPH = VacuumiPressure/Hydrostatic, ID = Identification