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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s of 6) XII . LINE LEAK DETECTOR TESTING © Check this box if line leak detectors (LLD) are NOT installed . (Do not complete this section.) :Y]: NNA 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 ? ❑ ❑ ❑ 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 ? ❑ I ❑ ❑ 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 ? ❑ I ❑ ❑ For any answer of "N" above, describe in Section X111 how and when these issues were or will be corrected. XIII . COMMENTS XIV, VACUUM I PRESSURE I 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 PW 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 ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail El Pass El Fail ❑ Pass E] 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 I 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.) 4 For any answer of "Fail" above, describe in Section XV how and when these issues were or will be corrected. XV. COMMENTS GPH = Gallon Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = VaaunvPressure/Hydrostatic, ID = Identification i