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RECEIVED D. Results of Testing/Servicing N110V 2 1 2013 Software Version Installed:VR 1.01 ENVIRONMENTAL Complete the following checklist: HEALTH DEPARTMENT X Yes No' Is the audible alar operational? X Yes No' Is the visual alar operational? X Yes - No' Were all sensors visually inspected,functionally tested,and confirmed operational? X Yes ii No' Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? Yes ❑ No' If alarms are relayed to a remote monitoring station,is all communications equipment(e.g.modem)operational? X WA X Yes ❑ No' For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment monitoring system ❑ WA detects a leak,fails to operate,or is electrically disconnected? If yes:which sensors initiate positive shut-down? (Check all that apply) X Sumprrrench Sensors; X Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failure/disconnection? X Yes; ❑ No. X Yes ❑ No' For tank systems that utilize the monitoring system as the primary tank overfill warning device(i.e. no,mechanical overfill prevention WA valve is installed),is the overfill warning alar visible and audible at the tank fill point(s)and operating property? If so,at what percent of tank capacity does the alartrigger? 95 % ❑ Yas`i Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaced and list the manufacturer name and model for all replacement arts in Section E,below. ❑ Yes' Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)n Product; ❑Water. If s,describe causes in Section E,below. X YesWas monitoring system set-up reviewed to ensure proper settings?Attach set up reports,if applicable X YesIs all monitoring equipment operational per manufacturer's specifications? In Section E below,describe how and when these deficiencies were or will be corrected. E. Comments: L2 DISP 1-2 ANNU LAR[MODLE VR 304 X PASS L4 DISP 34ANNULAR[MODLE VR 304 X PASS L 6 DISP 5-6 ANNULAR[MIDDLE VR 304 X PASS L 8 DISP 7-8 ANNULAR[MODLE VR 304 X PASS L 10 DISP 9-10 ANNULAR[MODLE VR 304 X PASS L 12 DISP 11-12 ANNULAR[MODLE VR 304 X PASS L 13 VENT DOX[MODLE VR 208 X PASS L 14 VENT BOX ANNULAR[MODLE VR 304 X PASS L 16 87 STP SUMPANNULAR[MODEL VR 304 X PASS L 18 87 FILL SUMP ANNULAR[MODLE VR 304 X PASS L 20 91 STP SUMPANNULAR[MODLE VR 304 X PASS L 22 91 FILL SUMPANNULAR[MODLE VR 304 X PASS L 24 DIESEL STP SUMP ANNULAR[MODLE VR 304 X PASS L 26 DIESEL FILL SUMP ANNULAR[MODLE VR 304 X PASS Monitoring System Certification Page 2 of 4 12107 2 2/21/07