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RECEIVED <br /> Underground Storage Tank <br /> Monitoring System Certification Form JAN 0 7 2022 <br /> ENVIRONMENTAL <br /> 7x LINE LEAK DETECTOR TESTING HEALTH DEPARTM NT <br /> ❑ Check this box if line leak detectors ARE NOT installed . (Do not complete this section. ) <br /> Simulated release rate verified : ( Check all that apply . ) Yes No NA <br /> El 3 GPH ❑ 0 . 1 GPH ❑ 0 . 2 GPH <br /> Has the testing apparatus been properly calibrated ? 0 ❑ ❑ <br /> For emergency generator tank systems , does the LLD create an audible and visual ❑ ❑ F7 <br /> alarm when a leak is detected ? <br /> For mechanical LLDs , does the LLD restrict the flow through the pipe when a 177 ❑ <br /> release is detected ? <br /> For electronic LLDs , does the turbine automatically shut off when a release is ❑ ❑ 177 <br /> detected ? <br /> For electronic LLDs , does the turbine automatically shut off if any portion of the ❑ El 0 <br /> monitoring system is disabled or disconnected ? <br /> For electronic LLDs , does the turbine automatically shut off if any portion of the F1 F 0 <br /> monitoring system malfunctions or fails a tightness test? <br /> For electronic LLDs , have all accessible wiring connections been visually inspected 171 ❑ <br /> El <br /> for kinks and breaks? <br /> Were all items on the equipment manufacturer' s maintenance checklist completed ? ❑ ❑ 1771 <br /> Were all LLDs confirmed operational within regulatory requirements ? T�01 ❑ ❑ <br /> LLD ID LLD Model Lines Monitored Pass Fail <br /> ❑ ❑ <br /> ❑ ❑ <br /> ® ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ <br /> ]EI <br /> Describe all answers marked "No " or "Fail" and proposed remedy in Section 9. <br /> List all monitoring equipment either replaced or repaired in Section 9 <br /> Page 4 of 6 <br />