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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page s of 6) XII . LINE LEAK DETECTOR TESTING AUG ❑ Check this box if line leak detectors (LLD) are NOT installed . (Do not complete this section.) This section must be completed If LLDs are installed. Y N NA I Was a leak simulated to verify LLD performance? IN, IN _ El all that apply.) Simulated leak rate verified : ® 3 GPH El 0A GPH_ ❑ 0. 2 GPH I ) I '- I ' I � �,� t )'- I ` _ 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] For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected? ❑ ❑ 0 For electronic LLDs , does the turbine automatically shut off when a leak is detected? ® ❑ _ ❑_ 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? ® ❑ ❑ For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? ® ❑ ❑ 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 Xlil 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. ) ® Vacuum ❑ Pressure ❑ Hydrostatic Sensor Functionality Interstitial Communication Sensor ID Component(s) Monitored by this Sensor Test Test S -9 87 SEC ® Pass ❑ Fail ® Pass ❑ Fail S - 10 VAPOR SEC ® Pass ❑ Fail ® Pass ❑ Fail S- 11 91 SEC ® Pass ❑ Fail ® Pass ❑ Fail S - 12 DIESEL SEC ® Pass ❑ Fail ® Pass ❑ Fail & 13 VENT SEC 87/91 /DSL ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail j ❑ Pass ❑ Fail ❑ Pass ❑ Fail i ❑ 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.) ❑ 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 "FAIL " above, describe in section XV how and when these issues were or will be corrected. XV . COMMENTS I GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification I