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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? [21 ❑ ❑ (Check all that apply.) Simulated leak rate verified : 0 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 ? ❑ I ❑ 0 For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected ? g ❑ ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected ? ❑ 1 ❑ W For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑ W1 For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ I ❑ 0 For electronic LLDs , have all accessible wiring connections been visually Inspected for kinks and breaks? ❑ I ❑ W1 Were all items on the equipment manufacturer's maintenance checklist completed? ® ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? ✓❑ ❑ ❑ For any answer of "N" above, describe in Section Xill how and when these issues were or will be corrected. XIII . COMMENTS XIV. VACUUM i PRESSURE / HYDROSTATIC MONITORING EQUIPMENT TESTING 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. System Type (Mark all that apply.) ❑ Vacuum ❑ Pressure ❑ Hydrostatic SSensor Functionality Interstitial Communication ensor lD Component(S) Monitored 6y This Sensor 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 ❑ Pass ❑ Fail How was Interstitial communication verified ? Simulated Leak at Far Ends of the Interstitial Space El 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 "Fall' above, describe in Section XV how and when these Issues were or will be corrected. XV. COMMENTS GPH = Gallon Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = VacuumvPressurelHydrostatic, ID = Identification