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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s 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? 0 ❑ [] (Check all that apply.) Simulated leak rate verified: ® 3 GPH E] 0 . 1 GPH E] 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 ? ❑ ❑ For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected? ® ❑ ❑ 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 ? ❑ ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? El ❑ ❑ For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? El1:1 ZI Were all items on the equipment manufacturer's maintenance checklist completed ? El ❑ Were all LLDs confirmed operational within regulatory requirements ? W1 10 1 ❑ 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 1 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 Sensor Functionality Interstitial Communication Sensor ID Component(S) Monitored By This Sensor Test Test ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail El 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 ❑ Visual Inspection ❑ Other (Describe the method in section XV below.) 01 Gau e 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 = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = VacuumiPressumlHydrostatic, ID = Identification