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Underground Storage Tank <br />Monitoring System Certification Form <br />a. MONITORING SYSTEM AND PROGRAMMING <br />A separate Monitefin-9 System Certification Form must be prepared for each control panel. <br />Make of Monitoring System <br />Model of Monitoring System <br />Software Version Installed <br />Control Panel <br />Control Panel <br />Veeder-Root <br />TLS -350 <br />Attach the post -certification reports if the monitoring system is capable of generating <br />Yes <br />No <br />NA <br />either, 0 Monitoring System Set-up E] Alarm History Report <br />All monitoring equipment is operational per manufacturer's specifications"? <br />El <br />El <br />Secondary containment systems are free of damage, debris, or liquid? <br />El <br />El <br />Are the audible and visual alarms operational? <br />Q <br />El <br />All sensors have been: 1) visually inspected for wiring Finks, breaks and residual <br />buildup on floats; and 2) tested for functionality and confrmed operational'? <br />Are all sensors installed to detect a release at the earliest opportunity in the <br />secondary containment? <br />The monitoring system set-up was reviewed, and proper settings confirmed? <br />❑� <br />Was the monitoring control panel's backup battery visually inspected, fu notionally <br />0 <br />tasted. and confirmed operational? <br />Does the flow of fuel stop at the dispenser if a release is detected in the under - <br />dispenser containment? <br />Does the turbine automatically shut dawn if the piping secondary containment <br />Ell <br />C <br />El <br />monitoring system fails to operate or is eledrically disconnected? <br />Does the turbine automatically shut dawn if the piping secondary containment <br />monitoring systern detects a release? Which sensors initiate positive shut down? <br />(C heck all that app l Sump r] UD <br />If monitoring system alarms are relayed to a remote monitoring center, is all <br />communication equipment operational? <br />Describe all answers marked'Wo r or'FaX and proposed remedy in Section 9. <br />List all monifofing equipment either replaced or repaired in Section 9 <br />Page 2 of 6 <br />