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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 N NA This section must be completed if LLDs are installed. Was a leak simulated to verify LLD performance? 0 ❑ ❑ (Check all that apply.) Simulated leak rate verified : Q 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 ? Q ❑ ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected? El ElQ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? 1:1 ElQ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? El 1:1Q For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? El E:10 Were all items on the equipment manufacturer's maintenance checklist completed? Q 1:1 EJ Were all LLDs confirmed operational within regulatory requirements? 0 1:1 ❑ For any answer of "N" above, describe in Section X111 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 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 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 belowj ❑ 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 RECD. - IN/ E D' APR 19 ? 010 ENVIRONMENTAL HEALTH DEPARTMENT GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification