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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM XII , LINE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors ( LLD) are NOT installed . (Do not complete this section.) Y N N/A This section must be completed if LLDs are installed. Was a leak simulated to verify LLD performance? ® ❑ ❑ (Check all that apply. ) Simulated leak rate verified : ® 3 GPH ❑ 0 . 1 GPH ❑ 0 . 2 GPH Was the test 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 ? ® ❑ ❑ 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 Xlll 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 ID Component )s) Monitored By This Sensor Sensor Functionality Interstitial Test Communication Test S1 87 Product ® Pass ❑ Fail ® Pass ❑ Fail S2 87 Vent ® Pass ❑ Fail ® Pass ❑ Fail S3 87 Vapor ® Pass ❑ Fail ❑ Pass ❑ Fail S4 DSL Product ® Pass ❑ Fail ® Pass ❑ Fail S5 DSL Vent ® Pass ❑ Fail ® Pass ❑ Fail S6 91 Product ® Pass ❑ Fail ® Pass ❑ Fail S7 91 Vent ® 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.) ❑ Gauge Was the vacuum or pressure restored to operating levels in 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