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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (page s of s) :1 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 verity LLD performance? O ❑ ❑ (Check all that apply ) Simulated leak rate verified X❑ 3 GPH ❑ 0 1 GPM ❑ 0 2 GPH Was the testing apparatus properly calibrated? n ❑ ❑ For emergency generator tank systems does the LLD create an audible and visual alarm when a leak is detected ❑ ❑ 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 off when a leak is detected ? ❑X ❑ ❑ For electronic LLDs does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑X EJ ❑ For electronic LLDs . does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑X ❑ ❑ For electronic LLDs have all accessible wiring connections been visually inspected for kinks and breaks? ❑X ❑ 1 ❑ Were all items on the equipment manufacturer s maintenance checklist completed ? ❑X ❑ 1 ❑ Were all LLDs confirmed operational within regulatory requirements ? Q 1 ❑ I ❑ For any answer of "M " above, describe in Section X111 how and when these issues were or will be corrected XIII . COMMENTS XIV. VACUUM i 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 VPN 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 ❑ Fa ❑ Pass ❑ Fail ❑ Pass ❑ Fa=t ❑ Pass ❑ Fail ❑ Pass ❑ Fal ❑ Pass ❑ Fail ❑ Pass ❑ Fal ❑ Pass ❑ Fail ❑ Pass ❑ Fad ❑ Pass ❑ Fail ❑ Pass ❑ Fast ❑ Pass ❑ Fail ❑ Pass ❑ Fal 1 11 Pass ❑ Fail ❑ Pass ❑ Fal ❑ Pass ❑ Fad ❑ Pass ❑ Fal ❑ Pass ❑ Fail ❑ Pass ❑ Faa ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Faa ❑ Pass El 170 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 GPH = Gallons Per Hour. Y = Yes N = No, NA = Not Applicable, VPH = Vac u miPressuml-lydrostatic: ID = Identification i l