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Site Address: <br />F. In -'rank Gauging f SER Equipment: <br />• <br />Date of Testing/Servicing: <br />❑ Check this box if tank gauging .is used only for inventory contral: <br />❑ Check this box if no tank gauging or SLR equipment is installed. <br />This section must be completed if in -tank gauging equipment is used to perform leak detection monitoring. <br />!'nmzA'A#P thw fnllnwino ehPArliet- <br />❑ No* <br />Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />❑ No* <br />Were all tank gauging probes visually inspected for damage and residue buildup? <br />❑ No* <br />Was accuracy of system product level readings tested? <br />❑ No* <br />Was accuracy of system water level readings tested? <br />s ❑ No* <br />4,Y—CS— <br />Were all probes reinstalled properly? <br />❑ No* <br />I Were all items on the equipment manufacturer's maintenance checirlist 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 />(`nnfh"]c fp the fnllnwin4 rhnrlrliat- <br />❑ Check this box if LLDs are not installed. <br />Yes <br />❑ No* <br />For equipment start-up or annual equipment c5%ffication, was a leak simulated to venf'y.LLD performanclP <br />❑ N/A <br />(Check all that apply) Simulated leak rate: Q'3 g.p.h.'; ❑ 0.1 g.p.h.Z; [10.2 g.p.h.2 <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 />Yes <br />❑ W <br />Was the testing apparatus properly calibrated? <br />❑ Yes <br />EM& <br />For mecbanical LLDs, does the LLD restrict product flow if it detects a leak? <br />❑ N/A <br />�j <br />❑ Yes <br />❑ W <br />For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? <br />CRIN/A <br />❑ Yes <br />❑ l)io* <br />For electronic L Ds, does the turbine automatically shut off if any portion of the monitoring system is disabled <br />DINA <br />or disconnected? <br />❑ Yes <br />❑ . * <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system <br />NIA <br />malf factions or fafls a test? <br />❑ Yes <br />❑ * <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 maruifacturer's maintenance checklist completed? . <br />* In the Section H, below, <br />T,z f'J�T : 4 'L'c ,, LCA' - -- - !; � r a Fib 71---e <br />Page 3 of 3 a3rot <br />