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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) <br /> XII. LINE LEAK DETECTOR TESTING <br /> ❑ Check this box if line leak detectors(LLD)are NOT installed. (Do not complete this section.) Y N NA <br /> This section must be completed if LLDs are installed. <br /> Was a leak simulated to verify LLD performance? ® ❑ ❑ <br /> Check all that apply.) Simulated leak rate verified: ® 3 GPH ❑ 0.1 GPH ❑ 0.2 GPH <br /> Was the testing apparatus properly calibrated? ® ❑ ❑ <br /> For emergency generator tank systems,does the LLD create an audible and visual alarm when a leak is detected? ❑ ❑ <br /> For mechanical LLDs,does the LLD restrict the flow through the pipe when a leak is detected? ® ❑ ❑ <br /> For electronic LLDs,does the turbine automatically shut off when a leak is detected? ® ❑ ❑ <br /> For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ® ❑ ❑ <br /> For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ® ❑ ❑ <br /> For electronic LLDs,have all accessible wiring connections been visually inspected for kinks and breaks? ® ❑ ❑ <br /> Were all items on the equipment manufacturer's maintenance checklist completed? ® ❑ ❑ <br /> Were all LLDs confirmed operational within regulatory requirements? ® ❑ ❑ <br /> For any answer of"N"above,describe in section Xlll how and when these issues were or will be corrected. <br /> XIII. COMMENTS <br /> XIV. VACUUM/PRESSURE/ HYDROSTATIC MONITORING EQUIPMENT TESTING <br /> ❑ Check this box if VPH monitoring is NOT used. (Do not complete this section.) <br /> This section must be completed if VPH monitoring is used to perform leak detection monitoring. <br /> System Type(Mark all that apply.) ®Vacuum ❑ Pressure ® Hydrostatic <br /> Sensor Functionality Interstitial Communication <br /> Sensor ID Component(s)Monitored by this Sensor Test Test <br /> L1 87A ANNULAR ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> L2 87B ANNULAR ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> L3 91 ANNULAR ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> L4 ADDITIVE ANNULAR ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> L5 87A FILL SUMP ® Pass ❑ Fail ® Pass ❑ Fail <br /> L7 87B FILL SUMP ® Pass ❑ Fail ® Pass ❑ Fail <br /> L9 91 FILL SUMP ® Pass ❑ Fail ® Pass ❑ Fail <br /> L11 ADDITIVE FILL/STP SUMP ® Pass ❑ Fail ® Pass ❑ Fail <br /> L12 ADDITIVE VENT SUMP ® Pass ❑ Fail ® Pass ❑ Fail <br /> S9 ADDITIVE PRODUCT ® Pass ❑ Fail ® Pass ❑ Fail <br /> S10 ADDITIVE VENT ® Pass ❑ Fail ® Pass ❑ Fail <br /> ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> How was interstitial communication verified? ® Simulated leak at far ends of the interstitial space. ❑Visual Inspection <br /> ❑ Other(Describe the method in section XV below.) ❑ Gauge <br /> Was the vacuum or pressure restored to operating levels in all interstitial spaces? ®Yes ❑ No(Describe the reason in section XV below.) <br /> For any answer of"FAIL"above,describe in section XV how and when these issues were or will be corrected. <br /> XV. COMMENTS <br /> GPH=Gallons per hour,Y=Yes,N=No,NA=Not applicable,VPH=Vacuum/Pressure/Hydrostatic,ID=Identification <br />