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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 6 of s) XII . LINE LEAK DETECTOR TESTING ❑ Check 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 ❑ 0. 1 GPH ❑ 0.2 GPH Was the testing apparatus properly calibrated ? 0 ❑ ❑ 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? ❑ I ❑ I W1 For electronic LLDs , does the turbine automatically shut off when a leak is detected? W1 1 ❑ 1 ❑ 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? QI ❑ I ❑ Were all items on the equipment manufacturer's maintenance checklist completed? ❑ 1 ❑ Were all LLDs confirmed operational within regulatory requirements? X ❑ ❑ For any answer of "N" above, describe in Section X111 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.) [a Vacuum ❑ Pressure ® Hydrostatic SSensor Functionality Interstitial Communication Sensor ID Component(S) Monitored By This Sensor Test Test S- 1 87 PRODUCT VAC m Pass ❑ Fail Pass ❑ Fail S-2 87 VENT VACW1 Pass ElFail W1Pass ❑ Fail S-3 87 ANNULAR VAC m Pass ❑ Fail Pass ❑ Fail S4 87 VAPOR VAC 0 Pass ❑ Fail W1 Pass ❑ Fail S-5 91 PRODUCT VAC Z Pass E] Fall W] Pass ElFail S-6 91 VENT VAC _ Pass ❑ Fail ® Pass ElFail S4 DSL PRODUCT VAC Z Pass ❑ Fail Pass ❑ Fail S-9 DSL VENT VAC ® Pass ❑ Fail 91 Pass ❑ Fail Pass Fail Pass Fail j SAO DSL-91 ANNULAR VAC � ❑ ® ❑ I El Pass _ ❑ Fail ❑ Pass [:1 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 all interstitial spaces? W1 Yes ❑ No (Describe the reason in section XV below.) For any answer of "Fall' 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 = Vacuurn/Pressure/1lydrostatic, ID = Identfication I