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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of B) 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. � - �l I Was a leak simulated to verify LLD performance? o ❑ ❑ (Check all that apply.) Simulated leak rate verified Q 3 GPH ❑ 0 1 GPH ❑ 0 2 GPH Was the testing apparatus properly calibrated? Q ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? ❑ 1 ❑ X❑ For mechanical LLDs does the LLD restrict the flow through the pipe when a leak is detected? ❑ ❑ X❑ For electronic LLDs , does the turbine automatically shut oft when a leak is detected? Q ❑ ❑ For electronic LLDs, does the turbine automatically shut off it 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 ❑ 1 ❑ For electronic LLDs have all accessible wiring connections been visually inspected for kinks and breaks ? ❑X ❑ ❑ Were all items on the equipment manufacturers maintenance checklist completed? Q ❑ ❑ Were all LLDs confirmed operational within regulatory requirements ? ® ❑ ❑ For any answer of "N " above, describe in Section X111 how and when these issues were or will be corrected. X111. COMMENTS XIV, VACUUM ! PRESSURE I HYDROSTATIC MONITORING EQUIPMENT TESTING ❑X 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 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 ❑ Fait ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail 1 ❑ Pass ❑ Fail How was interstitial communication venfied? ❑ Simulated Leak at Far Ends of the Interstitial Space ❑ Visual Inspection Other (pescnbe the method in section XV below ) 0 Gouge Was the vacuum or pressure restored to operating levels in all interstitial spaces? ❑ Yes ❑ No (Describe the mason 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 Per Hour, Y = Yes. N = No, NA = Not Applicable- VPH = VacuumrPressure/Hydrosiatic 10 = Identification