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Underground Storage Tank <br /> Monitoring System Certification Form <br /> I. LIFE LEAK DETECTOR TESTING <br /> ❑ Check this box if line leak detectors ARE NOT installed. fDo not complete this section.) <br /> Simulated release rate verified: (Check al that apply.) Yes No NA <br /> 0 3 GPH ❑ 0-1 GPH ❑ 0,2 GPH <br /> Has the testing apparatus been properly calibrated? CK ❑ ❑ <br /> For emergency generator tank systems, does the LLD create an audible and visual <br /> alarm when a leak is detected? <br /> For mechanioal LLDs, does the LLD restrict the flow through the pipe when a Q ❑ <br /> release is detected? <br /> For electronic LLD% does the turbine automatically shut off when a release is 0 ❑ ❑ <br /> detected? <br /> For electronic LLDs, does the turbine automatically shut off if any portion of the ❑ ❑ ❑ <br /> monitoring system is disabled or disconnected? <br /> For electronic LLDs, does the turbine automaticaliy shut of if any portion of the 0 ❑ ❑ <br /> monitoring system malfunctions or fails a tightness test? <br /> For electronic LLDs., have all acoessible wiring connections been visually inspected ❑ ❑ <br /> for kinks and breaks? <br /> Were all items on the equipment manufacturer's maintenance checklist completed? �I ❑ ❑ <br /> Were all LLDs confirmed operational within regulatory requirements? � 0 ❑ <br /> LLD ID LLD WdO bees Monitored Pass Fart <br /> 01 DPLLD Regular � ❑ <br /> 02 DPILLD I Premium � Q <br /> Q3 DPLID Diesel ❑ <br /> ❑ ❑ <br /> ❑ El <br /> ❑ a <br /> Describe all answers Marked Who"or wFail"and proposed remedy in Section S. <br /> List all monitoring equipment either replaced or repaired in Section 19 <br /> Page 4 of 6 <br />