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0 0 <br />Site Address: E" -4'c -j- Date of Testing/Servicing: I? `? -0 S— <br />F. In -Tank Gauging / SIR Equipment: ❑ Check this box if tank gauging is used only for inventory control. <br />❑ Cheek this lox if no tank gauging or STR equipment is installed <br />This section must be completed if in -tank gauging equipment is used to perform leak detection monitoring. <br />Cmnplete the foliowin} checklist: <br />Yes ❑ No* <br />Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />es ❑ No* <br />Were all tank gauging probes visually inspected for damage and residue buildup? <br />es ❑ No* <br />Wa s accuracy of system product level readings tested? <br />❑ No* <br />Was accuracy of system water level readings tested? <br />es ❑ No* <br />Were all probes reinstalled properly? <br />Yes ❑ No* <br />Were all items on the equipment manufachuer'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): Check this box if LLDs are not installed <br />R.�.. <br />Yes <br />. <br />❑ No* <br />For equipment start-up or amoral equipment ccrtification, was a leak simulated to verify LLD performance? <br />❑ N/A <br />(Check all that apply) Simulated leak rate: M 3 g.p.h.c; ❑ 0.1 g.p.h.Z; ❑ 0.2 g.p.h.' <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 />No* <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />Messl❑ <br />[INo* <br />Was the testing apparatus properly calibrated? <br />❑ No* <br />For mechanical LLDs, does the LLD restrict product flow if it detects a leak? <br />❑ NIA <br />❑ Yes <br />❑ Aio* <br />For electronic LLDs, does the turbine automatically shut Off if the LLD detects a leak? <br />❑ yes <br />❑ <br />For electronic LLD%, does the turbine amomatieally shut off if any portion of the monitoring system is disabled <br />NIA <br />or disconnected'1 <br />❑ Yes <br />❑ ,No* <br />For elearomc LLDs, does the turbine automatically shut off if any portion of the monitoring system <br />EJ N/A <br />malfunctions or fails a test? <br />❑ Yes <br />❑ o* <br />For electronic LLDs, have all accessible wiring connections been visually inspected? <br />f NNIA <br />12"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 ToI <br />o3ro1 <br />