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0 <br />Site Address: <br />0 <br />Date of Testing/Serviemg: <br />F. In -Tank Gauging / SIR Equipment: ❑ Check this box if tank gauging is used only for inventory control. <br />❑ Check this box if no tank ganging or SIR equipment is installed. <br />This section must be completed if in -tank gauging equipment is used to perform leak detection monitoring. <br />Complete the followine checklist <br />❑ NO <br />Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />Q No* <br />Were all tank ganging probes visually inspected for damage and residue buildup? <br />❑ No* <br />Was accuracy of system product level readings tested? <br />❑ No* <br />Was acarracy of system water level readings tested? <br />Yes ❑ No* <br />Were all probes reinstalled properly? <br />Yes ❑ No* <br />Were all items on the equipment manufacturer's maintenance checklist completed? <br />M Mc amuun Q, oemw, aescrrne now and when these deficiencies were or will be corrected. <br />G. Line Leak Detectors (LLD): ❑ Check this box if LLDs are not installed. <br />i,um cre <br />me rmrowm <br />CneCllh.4t: <br />Yes <br />❑ No* <br />For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? <br />❑ N/A <br />(Check all that apply) Simulated teak rate: ❑ 3 g.p.h.'; ❑ 0.1 g.p.k2; ❑ 0.2 g.p.h.Z <br />Notes: 1. Required for equipment start-up certification and annual certification. <br />2. Unless mandated by local agency, certification required only for electronic LLD start-up. <br />Y <br />❑ No* <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />- es <br />❑ No* <br />Was the testing apparatus properly calibrated? <br />❑ Yes <br />❑ l>e* <br />For mechanical LLDs, does the LLD restrict product flow if it detects a leak? <br />ff'N/A <br />es <br />❑ No* <br />For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? <br />❑ NIA <br />Yes <br />❑ No* <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled <br />❑ NIA <br />or disconnected? <br />Yes <br />❑ No* <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system <br />❑ N/A <br />matfimetions or fails a test? <br />Yes <br />❑ No* <br />For electronic LLDs, have all accessible wiring connections been visually inspected? <br />❑ N/A <br />Yes <br />❑ No* <br />Were all items on the equipment manufacturer's maintenance checklist completed? <br />In the Section H, below, describe how and when these deficiencies were or will be corrected. <br />H. Comments: <br />Page 3 of 3 03101 <br />