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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 ? FE 11El 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 ? FlE For electronic LLDs, does the turbine automatically shut off when a leak is detected ? ❑ ElFor 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? E ❑ ❑ Were all items on the equipment manufacturer' s maintenance checklist completed ? E ❑ I ❑ Were all LLDs confirmed operational within regulatory requirements? E ❑ ❑ 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. ) ® Vacuum ❑ Pressure ❑ Hydrostatic Sensor ID Component) s) Monitored By This Sensor Sensor Functionality Interstitial Test Communication Test S1 87 Product ® Pass ❑ Fail ® Pass ❑ Fail 52 87 Annular ® Pass ❑ Fail ® Pass ❑ Fail S3 87 Vent ® Pass ❑ Fail ® Pass ❑ Fail S4 91 Product ® Pass ❑ Fail ® Pass ❑ Fail S5 91- DSL Annular ® Pass ❑ Fail 1 ® Pass ❑ Fail 56 DSL Product ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail I ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ 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 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 r HE E r HIPAH IL . .