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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. ® El ElWas a leak simulated to verify LLD performance? (Check all that apply.) Simulated leak rate verified : ® 3 GPH ❑ 0 . 1 GPH ❑ 0 . 2 GPH F1Was the test apparatus properly calibrated ? ® ❑ For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? El ❑❑ 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 ? ® 171 El 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? ® El El Were all items on the equipment manufacturer' s maintenance checklist completed ? ® 171 ❑ 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 S17 87 Product ® Pass ❑ Fail ❑ Pass ❑ Fail S18 87-91 Vapor Line ® Pass ❑ Fail ❑ Pass ❑ Fail S19 87 Vent ® Pass ❑ Fail ❑ Pass ❑ Fail S20 91 Product ® Pass F1 Fail F'1 Pass ❑ Fail S21 91 Vent ® Pass ❑ Fail F1 Pass ❑ Fail S22 DSL Product ® Pass ❑ Fail ❑ Pass ❑ Fail S23 DSL 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 For any answer of "Fail" above, describe in Section XV how and when these Issues were or will be corrected. XV . COMMENTS i i I