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{ 1 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s of 6) XII . LINE LEAK DETECTOR TESTING FCheck oxif 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 : ❑X 3 GPH ❑ 0 . 1 GPH ❑ 0 .2 GPH Was the testing apparatus properly calibrated? 0 ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? ❑ ❑ 0 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? ❑ ❑ X❑ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ ❑ 0 For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? ❑ ❑ Z Were all items on the equipment manufacturer's maintenance checklist completed? 0 ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? x❑ I ❑ ❑ For any answer of "N" above, describe in Section Xl/l how and when these issues were or will be corrected. XIII . COMMENTS XIV. VACUUM / PRESSURE / HYDROSTATIC MONITORING EQUIPMENT TESTING ❑X 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 Communication Test Test ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ 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) For any answer of "Fail' above, describe in Section XV how and when these issues were or will be corrected. XV. COMMENTS R E TisTJ r 9:i PLAY . 1 ? 0i9 ENVIRONMENTAL HEALTH DEPARTMENT GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuum/Pressure/Hydrostafic, ID = Identification