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sitoring System Certification • <br /> Site Address: 470 N MAIN ST Date of Testing/Service: 12/02/2003 <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 ❑No' Has all input wiring been inspected for proper entry and termination,including testing for ground faults? <br /> ❑Yes ❑No' Were all tank gauging probes visually inspected for damage and residue buildup? <br /> ❑Yes ❑No' Was accuracy of system product level readings tested? <br /> ❑Yes ❑No* Was accuracy of system water level readings tested? <br /> Yes NO* Were all probes reinstalled property? <br /> ❑Yes E]Nod Were all items on the equipment manufacturers'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 /> Complete the following checklist: <br /> IFor equipment start-up or annual equipment certification,was a leak simulated to verify LLD performance? <br /> N No' ❑N/A (Check all that apply)Simulated leak rate: Q 3 g.p.h ❑0.1 g.p.h 00.2 g.p.h <br /> No' Were all LLDs confirmed operational and accurate within regulatory requirements? <br /> No' Was the testing apparatus properly calibrated? <br /> No' ❑N/A For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> No' ®N/A For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? <br /> No' Q N/A For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? <br /> No* Q N/A For electronic LLDs,does the turbine automaticallyshut off if any portion of the monitoring system malfunctions or fails a test? <br /> No* Q N/AFor electronic LLDs,have all accessible wiring connections been visually inspected? <br /> M11No' Were all items on the equipment manufacturers'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 3 of 3 <br />