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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page s 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? N ❑ ❑ Check all that apply.) Simulated leak rate verified : N 3 GPH ❑ 0 . 1 GPH ❑ 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 ? ❑ ❑ N For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected ? N ❑ ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected ? N ❑ ❑ 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? N ❑ ❑ For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? N ❑ ❑ Were all items on the equipment manufacturer's maintenance checklist completed ? N ❑ ❑ Were all LLDs confirmed operational within regulatory requirements ? N ❑ ❑ 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.) N Vacuum ❑ Pressure N Hydrostatic Sensor Functionality Interstitial Communication Sensor ID Component(s) Monitored by this Sensor Test Test L1 87A ANNULAR N Pass ❑ Fail ❑ Pass ❑ Fail L2 87B ANNULAR N Pass ❑ Fail ❑ Pass ❑ Fail L3 91 ANNULAR N Pass ❑ Fail ❑ Pass ❑ Fail L4 ADDITIVE ANNULAR N Pass ❑ Fail ❑ Pass ❑ Fail L5 87A FILL SUMP N Pass ❑ Fail N Pass ❑ Fail L7 87B FILL SUMP N Pass ❑ Fail N Pass ❑ Fail L9 91 FILL SUMP N Pass ❑ Fail N Pass ❑ Fail L11 ADDITIVE FILL/STP SUMP N Pass ❑ Fail N Pass ❑ Fail L12 ADDITIVE VENT SUMP N Pass ❑ Fail N Pass ❑ Fail S9 ADDITIVE PRODUCT N Pass ❑ Fail N Pass ❑ Fail S10 ADDITIVE VENT N Pass ❑ Fail N Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail How was interstitial communication verified ? N Simulated leak at far ends of the interstitial space . El Visual Inspection ❑ Other (Describe the method in section XV below.) ❑ Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? N 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 = VacuumlPressure/Hydrostatic, ID = Identification