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0 <br />Site Address: <br />0 <br />Date of Testing/Servicing: <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 gauging 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 following checklist: <br />(Yes <br />❑ <br />No* <br />Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />[tj'Yes <br />❑ <br />Na* <br />Were all tank gauging probes visually inspected for damage and residue buildup? <br />UrVes <br />❑ <br />No* <br />Was accuracy of system product level readings tested? <br />Yes <br />❑ <br />No* <br />Was accuracy of system water level readings tested? <br />Z'Yes <br />❑ <br />No* <br />Were all probes reinstalled properly? <br />es <br />❑ <br />No* <br />Were all items on the equipment manuficbuer's maintenance checklist completed? <br />* In the Section H, below, describe how and when these deficiencies were or will be corrected. <br />G. Line Leak Detectors (LLD): <br />f amnirtr thv fntlawino eherklivt_ <br />❑ Check this box if LLDs are not installed. <br />91 -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 leak rate: ®'3 g.p.h. ; ❑ 0.1 g.p.h.: ❑ 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 />QrYes <br />❑ No* <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />p'Yes <br />❑ No* <br />Was the testing apparatus property calibrated? <br />❑ Yes <br />IRNo* <br />For mechanical LLDs, does the LLD restrict product flow if it detects a leak? <br />❑ N/A <br />❑ Yes <br />❑ No* <br />For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak'? <br />grf4lA <br />❑ Yes <br />❑ No* <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled <br />p -N/A <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 />91 -N/A <br />malfunctions or fails a test? <br />❑ Yes <br />❑ No* <br />For electronic LLDs, have all accessible wiring connections been visually inspected? <br />29'N/A <br />p'Yes <br />❑ No* <br />I Were all items on the equipment manufacturer's maintenance checklist completed? <br />* In the Section H, below, describe bow and when these deficiencies were or will he corrected. <br />H. Comments: <br />L <br />Page 3 of 3 03/01 <br />