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Site Address: Pa f Testing/Servicing: I F. In-Tank Gauging/ SIR Equipment: ❑ Check this box if tank gauging is used only for inventory control. U Check this box if no tank gauging or SIR equipment is installed. This section must be completed il'in-lank gaugiltg e(luipntent is used to perlorm leak detection monitoring. Complete the following checklist: ❑ Yes ❑ No* I Has all input wiring been inspected leer proper entry and termination, including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of sys(em product level readings tested? ❑ Yes ❑ No* Was accuracy of system water level readings tested? ❑ Yes ❑ No* Were all probes reinstalled properly'? ❑ Yes ❑ No* IWere nll items on the equipment neamrlac(trrer's innintenanee checklist completed? * In the section H, below,describe Trow and when these deficiencies were or will be corrected. G. Dine Leak Detectors (LLD): ❑ Check This box if 11,1)s are not installed. Complete the following checklist: ❑ Yes ❑ No* For equipment start-up rn• annual equipment certification, was a leak simulated to verify LLD performance? ❑ N/A (Check all that aleph} Simulated leak rate: ❑ 3 g.p.h., ❑ 0.1 g.p.h ❑ 0.2 g.p.h. ❑ Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? ❑ Yes ❑ No* Was the testing apparatus properly calibrated? ❑ Yes ❑ No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ❑ N/A U Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled, ❑ N/A or disconnected? ❑ Yes Cl No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system ❑ NIA malfunctions or fails a test? ❑ Yes ❑ No* For electronic LCDs, have all accessible wiring connections been visually inspected? ❑ N/A ❑ Yes ❑ No* Were all items on the equipment nramifacturer's maintenance checklist completed? * In the Section H, below,describe how and when these deficiencies were or will be corrected. H. Comments: Page 3 of 3 05/00