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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) XII . LINE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors (LLD) are NOTinstalled . (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? N El ❑ (Check all that apply.) Simulated leak rate verified : ❑X 3 GPH ❑ 0 . 1 GPH ❑ 0 .2 GPH Was the testing apparatus properly calibrated ? X ❑ ❑ 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? tElo ❑X For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected ? X❑ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? XX For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? X❑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 I HYDROSTATIC MONITORING EQUIPMENT TESTING ❑ Check this box if VPH monitoring is NOTused . (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. ) ❑X Vacuum ❑ Pressure [] Hydrostatic Sensor ID Component(S) Monitored By This Sensor Sensor Functionality Interstitial Communication Test Test S-9 87 PRODUCT LINE ❑X Pass ❑ Fail ❑X Pass ❑ Fail S-10 87 VENT LINE [Z Pass ❑ Fail QPass ❑ Fail S-11 VAPOR RETURN LINE [gPass ❑ Fail QPass ❑ Fail S- 12 91 PRODUCT LINE QPass ❑ Fail QPass ❑ Fail S-13 91 VENT LINE ❑X Pass ❑ Fail QPass ❑ 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? ❑X 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? ❑X 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 = Vacuum/Pressure/Hydrostatic, ID = Identification i