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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of )) 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 ? © ❑ ❑ 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? ❑ ❑ W1 I 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? ® ❑ ElFor electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks ? ❑ ❑ W ❑ Were all items on the equipment manufacturer's maintenance checklist completed ? 121 ❑ ❑ 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. X1110 COMMENTS XIV. VACUUM / PRESSURE / HYDROSTATIC MONITORING EQUIPMENT TESTING Check this box if VPH monitoring is NOF 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 SSensor Functionality Interstitial Communication ensor 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 LJ 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 GPH = Galion Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = VacwnvPressue"drostatic, ID = Identification