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Underground Storage Tank <br /> Monitoring System Certification Form <br /> 7 LINE L,ETK` ;DPTCTCJF� TEII ' <br /> t. <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 . ) s� <br /> Y No <br /> x3 GPH 00 . 1 GPH ❑ 0 . 2 GPH ! <br /> Has the testing apparatus been properly calibrated ? x ❑ ❑ <br /> For emergency generator tank systems , does the LLD create an audible and visual alarm ❑ x <br /> when a leak is detected ? <br /> For mechanical LLDs , does the LLD restrict the flow through the pipe when a release is ❑ x <br /> detected ? <br /> For electronic LLDs , does the turbine automatically shut off when a release is detected ? x ❑ <br /> For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring x ❑ <br /> system is disabled or disconnected ? <br /> For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring x ❑ <br /> system malfunctions or fails a tightness test? <br /> For electronic LLDs , have all accessible wiring connections been visually inspected for x ❑ <br /> kinks and breaks ? <br /> Were all items on the equipment manufacturer' s maintenance checklist completed ? x ❑ ❑ <br /> Were all LLDs confirmed operational within regulatory requirements ? x ❑ ❑ <br /> LLD ID LLD Model Lines Monitored Pass Fail <br /> Q1 V/R 8484 87 X ❑ <br /> Q2 V/R 8484 91 X ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <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 /> RECEIVED <br /> OCT 18 2022 <br /> ENVIRONMENTAL HEALTH Page 4 of 6 <br /> DEPARTMENT <br />