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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) 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 GPM ❑ 0.2 GPH Was the testing apparatus properly calibrated? ED ❑ ❑ For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? ❑ ❑ ED 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? ® ❑ ❑ For any answer of "M' above, describe in section Xlll how and when these issues were or will be corrected. XIII . COMMENTS See Leak Detector Form 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 Functionality Interstitial Communication Sensor ID Component(s) Monitored by this Sensor 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 ❑ 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.) Foran answer of "FAIL" above, describe in section XV how and when these issues were or will be corrected. XV. COMMENTS GPH = Gallom per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacurm/PressurelHydrostatic, ID = Identification