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UNDERGROUND 'STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ' Page 5 of 6 X11. LINELEAK ' DETECTOR TESTING FCF-1 heck 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? © ❑ (Check all that apply.) Simulated leak rate verified : © 3 GPH E] 0 . 1 GPH E] 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? ✓❑ ❑ ❑ 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 ? ❑ I ❑✓ ❑ 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? Q ❑ ❑ 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 ' GENERATOR SYSTEM EXEMPT FROM POSITIVE SHUTDOWN, FINAL INSPECTION AND LEAK TEST PERFORMED WITH INSPECTOR PRESENT, XIV. VACUUM / PRESSURE I 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 Communication 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 I ❑ 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 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 J " ENVIRONIVIEN Tl PA i m F, I f GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification