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Underground Storage Tank Monitoring System Certification Form S. MONITORING SYSTEM AND PROGRAMMING A separate Monitoring System Certffication 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 TLS-450 01G.H. 33.53 Attach the post-certification reports if the rnonitoring system is capable of ge,,Ig Yes No NA either,` MMonitoring System Set-up ® ,alarm History Report Al 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 ) tested for functionality and confirmed operational? Are all sensors installed to detect a release at the earliest opportunity in the i ❑ secondary containment? _ The monitoring system set-up was reviewed, and proper settings confirmed? ❑ a Was the monitoring control panel's Backup battery visually inspected, functionally ER ❑ 0 tested, and confirmed operational? _ Does the F1 ow of fuel stop at the dispenser if a release is detected in the under- 0 ❑ ❑ dispenser containment? Does the turbine automatically smut down if the piping secondary containment 9 ❑ 0 monitoring system fails to operate or is electrically disconnected? Does the turbine automatically shut down if the piping secondary containment monitoring system detects a felease? Which sensors initiate positive shut down? ® ❑ ❑ (Check all that apply) 0 Sump ® UDC If monitoring system alarms are relayed to a remote monitoring center, is all ❑ ❑ 0 communication equipment operational" _ Describe all answers marked "ilio"or "Fail"and proposed remedy in Section 9. List all mon doring equipment either replaced or repaired in Section 9 Page 2 of