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4toring System Certification • <br />Site Address: 153 E 11TH ST Date of Testing/Service: 02/10/2004 <br />QC -D-3 <br />D. Results of Testing/Servicing <br />Software Version Installed: <br />Complete the following checklist: <br />X Yes I <br />nNO-1 <br />Is the audible alarm Operational? <br />❑X Yes <br />❑ No' <br />Is the visual alarm Operational? <br />Q Yes <br />No • <br />Were all sensors visually inspected, functionally tested, and confirmed operational? <br />❑X Yes <br />❑ No' <br />Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not <br />interfere with their proper operation? <br />YesNo' <br />X NIA <br />If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) operational? <br />X❑ Yes <br />❑ No' <br />❑ N/A <br />For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment <br />monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive <br />shut -down? (check all that apply) ❑X Sump/french Sensors; ❑ Dispenser Containment Sensors. <br />Did you confirm positive shut -down due to leaks and sensor failure/disconnection? ❑X Yes ❑ No <br />X Yes <br />❑ No • <br />❑ N/A <br />For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e.: no mechanical <br />overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tank fill points(s) and operating <br />properly? If so, at what percent of tank capacity does the alarm trigger? ao % <br />❑ Yes' <br />❑X No <br />Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaced and list the <br />manufacturer name and model for all replacement parts in Section E, below. <br />❑ Yes•X❑ <br />No <br />Was liquid found inside any secondary containment systems designed as dry systems? (check all that apply) ❑ Product; <br />❑ Water. If yes, describe causes in Section E, below. <br />❑X Yes <br />❑ No <br />Was monitoring system set-up reviewed to ensure proper settings? Attach set-up reports, if applicable. <br />❑X Yes <br />❑ No • <br />Is all monitoring equipment operational per manufacturers'specifications? <br />' In Section E below, describe how and when these deficiences were or will be corrected. <br />E. Comments: <br />Page 2 of 3 Based on CA form dated 03/01 <br />