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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of s) 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? ❑ ❑ ❑ (Check all that apply.) Simulated leak rale verified: ❑X 3 GPH ❑ 0. 1 GPH ❑ 0. 2 GPH Was the testing apparatus properly calibrated? X ❑ ❑ For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? ❑ ❑ 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? 0 ❑ ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑X ❑ I ❑ For electronic LLDs, does the turbine automatically shut off If any portion of the monitoring system malfunctions or fails a test? ❑X ❑ I ❑ For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? UX` t13113 0Were all items on the equipment manufacturers maintenance checklist completed? d ❑ Were all LLDs confirmed operational within regulatory requirements? 0 For any answer of "N" above, describe In Section X111 how and when these Issues were or will be corrected. XIII. COMMENTS XIV, VACUUM / 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.) 0 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 ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail El Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall How was interstitial communication verified? ❑ Simulated Leak at Far Ends of the interstitial Space ❑ Visual inspection Other Describe the method in section XV below ) 0 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 Sectlon XV how and when these Issues were or will be corrected. XV. COMMENTS GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = VaaxrnVPmssure4iydrostak ID = tdertlication .