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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? _ W] ❑ ❑ (Check al/ that apply.) Simulated leak rate verified: ® 3 GPH ❑ 0. 1 GPH ❑ 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? ❑ ❑ Z 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? © El ❑ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? El El For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? Z ❑ ❑ For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks? Q ❑ ❑ Were all items on the equipment manufacturer's maintenance checklist completed? Z ❑ ❑ 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 m Q 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 SSensor Functionality Interstitial Communication ensor ID Component(S) Monitored By This Sensor 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 ❑ 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 F1 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 = Gallon Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuun-Wressure/Hydrostatic, ID = Identification