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Underground Storage Tank <br />!Monitoring System Certification Form <br />S. MO N ITORING SYSTEM AND P ROG RAMMIN <br />A separste Monitoring System Certi'fi'cation Form must be prepared for each control panel. <br />Make of Monitoring System Model of Monitoring System Software Version Installed <br />Control Panel Control Panel <br />Veeder Root TLS 350 336,02 <br />Attach the post -certification reports if the monitoring system is capable of gen&rat'n Yes No NA <br />either. El Monitoring System Set-up ® Alarm History Report <br />All monitoring equipment is operational per manufacturer's specifications? <br />El <br />17 <br />Secondary containment systems are free of damage, debris, or liquid? <br />Tr <br />17 <br />Are the audible and visual alarms operational? <br />17 <br />in <br />Ali sensors have been: 1) visually inspected for wiring kinks, breaks and residual <br />buildup on floats; and ) tested for functionality and confirrned operational`? <br />Are all sensors installed to detect a release at the earliest opportunity in the <br />secondary containment? <br />The monitoring system setup was revEewed, and proper settings confirmed? <br />® <br />0 <br />El <br />Was the monitoring control panel's backup battery visually inspected, functionally <br />tested, and confirmed operational? <br />Does the flow of fuel stop at the disperser if a release is detected in the under - <br />dispenser containment? <br />Does the turbine automatically shut down if the piping secondary containment <br />monitoring system fails to operate or is electrically disconnected? <br />Does the turbine automaticaBy shut down if the piping secondary containment <br />monitoring system detects a release? Which sensors initiate positive shut clown's <br />© <br />� <br />(Check all that apply) F1 Sum UDC <br />�El <br />If monitoring system warms are relayed to a remote monitoring center, is all <br />_ <br />r <br />E) <br />communication equipment operational? <br />Describe all answers marked Wo" or "Fail" and proposed remedy in Section S. <br />List all momtoring equipment either replaced or repaired in Section 9 <br />Page 2 of 6 <br />