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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) XVI. LINE LEAK DETECTOR TESTING I— 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? r r r (Check all that apply.) Simulated leak rate verified: P7 3 GPH r 1.1 GPH r 0.2 GPH Was the testing apparatus properly calibrated? r r r For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? r r r For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected? r r r For electronic LLDs, does the turbine automatically shut off when a leak is detected? r r r For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? r r For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? r r I✓ For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks? r r r Were all items on the equipment manufacturer's maintenance checklist completed? r r r Were all LLDs confirmed operational within regulatory requirements? r r r 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/HYDROSTATIC MONITORING EQUIPMENT TESTING W 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. S stem Type Mark all that apply.) r Vacuum r Pressure r Hydrostatic Sensor ID Component(s) Monitored by this Sensor Sensor Functionality Interstitial Communication Test Test r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail F-Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail I-Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail How was interstitial communication verified? r Simulated leak at far ends of the interstitial space. r Visual Inspection r Other(Describe the method in section XV below.) r Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? r Yes r No (Describe the reason in section XV below.) For any answer of"N"above, describe in section XIII 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