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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? ® ❑ I ❑ For any answer of "N" above, describe in Section Xlll how and when these issues were or will be corrected. XIII . COMMENTS i c t XIV. VACUUM/PRESSURE/ HYDROSTATIC MONITORING EQUIPMENT TESTING i ❑ 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 F Pass ❑ Fail S2 91 Product ® Pass ❑ Fail ® Pass ❑ Fail S3 Vent Gas ® Pass ❑ Fail ® Pass ❑ Fail S4 91 Vapor ❑ Pass ❑ Fail ® Pass ❑ Fail S5 DSL Prod ® Pass ❑ Fail ® Pass ❑ Fail i S6 DSL Vent ❑ Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ 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