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"Pp?ndix IX Overfill Preven Underground Storage Tank TYP tion Equipment Inspection E OF ACTION Report F ❑Installation Orh1 TAiij 1. FACILITY INFORMATION ❑Repair i . CERs ID Underground Storage Tank �— Monitoring Sy� stem Certification Form r 7. LINE LEAK DETECTOR TESTING / Check this box if line leak detectors ARE NOT installed. (Do not Complete this section.) ❑ )(es No NA Simulated release rate verified: (Check all that apply-) I ) p 3 GPH ❑ 0.1 GPH ❑0.2 GPF-I 0 ❑ ❑ % Has the testing apparatus been properly calibrated? For emergency generator tank systems, does the LLD create an audible and visual ❑ ❑ 0 F alarm when a leak is detected? For mechanical LLDs, does the LLD restrict the flow through the pipe when a ❑ ❑ C release is detected? For electronic LLDs, does the turbine automatically shut off when a release is ❑ ❑ cot detected? o For electronic LLDs, does the turbine automatically shut off if any portion of the ❑ ❑ 0 Ma%/i, monitoring system is disabled or disconnected? S16< For electronic LLDs, does the turbine automatically shut off if any portion of the [-I El � ervic monitoring system malfunctions or fails a ti htness test? aVid For electronic LLDs, have all accessible wiring connections been visually inspected ❑ ❑ 0 ntra for kinks and breaks? 0C li Were all items on the equipment manufacturer's maintenance checklist completed? ❑ ❑ ❑ /C 3� 8�` Were all LLDs confirmed operational within regulatory requirements? 0 ❑ ❑ T L,LD lD LLD Model \R' Lines Monitored Pass Fail 87 99 LD 21000 87 LINE 0 ❑ 17 99 LD "2A00 87 LINE 0 ❑ 91 99 LD 2.000 91 LINE O ❑ CF ❑ ❑ CO' ❑ ❑ iic a ❑ ❑ �� ❑ Cl ❑ ❑ Describe all answers marked "No"or "Fail" List all monitoring equipment either replaced or and repaired remedy in Section 9. paoe d in Section 9 Page 4 of 6 r l�c t 21�Z(zu