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Underground Storage Tank Monitoring System Certification Form 5. MONITORING SYSTEM AND PROGRAMMING A separate Monitoring System Certification Form must be prepared for each control panel. Make of Monitoring System Model of Monitoring System Software Version Installed Control Panel Control Panel Veeder-Root TLS350 421.00 Attach the post-certification reports if the monitoring system is capable of generating Yes No NA either; ®Monitoring System Set-up ® Alarm History Report All monitoring equipment is operational per manufacturer's specifications? ® ❑ Secondary containment systems are free of damage, debris, or liquid? ® ❑ Are the audible and visual alarms operational? ® ❑ All sensors have been: 1) visually inspected for wiring kinks, breaks and residual ® ❑ ❑ buildup on floats; and 2) tested for functionality and confirmed operational? Are all sensors installed to detect a release at the earliest opportunity in the ® ❑ ❑ secondary containment? The monitoring system set-up was reviewed, and proper settings confirmed? ® ❑ ❑ Was the monitoring control panel's backup battery visually inspected, functionally ® ❑ ❑ tested, and confirmed operational? Does the flow of fuel stop at the dispenser if a release is detected in the under- ❑ ❑ dispenser containment? Does the turbine automatically shut down if the piping secondary containment ❑ ❑ monitoring system fails to operate or is electrically disconnected? Does the turbine automatically shut down if the piping secondary containment monitoring system detects a release? Which sensors initiate positive shut down? ❑ ❑ (Check all that apply) ❑ Sump ❑ UDC If monitoring system alarms are relayed to a remote monitoring center, is all ® ❑ ❑ communication equipment operational? Describe all answers marked "No"or "Fail"and proposed remedy in Section 9. List all monitoring equipment either replaced or repaired in Section 9 Page 2 of 6