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x,,..11 u.g.Iy>icut 4-el uueatwn Facility Name: Three Palms Grocery _ 6atcui icsttng,servtnng: 11121 X02 D. Results of Testing/Scrvicing Cum lete the following checklist: ❑ Yes ❑ No. Is the monitoring system operational per manufacturer's specifications? (21 Yes ❑ No' Is the audible alar operational'? 18 Yes ❑ No* Is the visual alar operational'? Yes ❑ No" Were all sensors visually inspected, tested, and confirmed operational? ❑ Yes ❑ No* Were all sensors and probes rcinstailed ro eriv? ❑ Yes Bl No' Is all monitoring,equipment secured from unauthorized tampering? Cl Yes ❑ No* if alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) BI N/A I operational? Yes ❑ No* I If needed by any monitoring equipment,are replacement fuses and/or batteries available? ❑ N/A ❑ Yes ❑ No* For pressurized piping systems,does the turbine automatically shut down if the piping secondary containment 1 N/A monitoring system detects a leak, fails to operate,or is electrically disconnected? If yes: which sensors initiate positive shut-down'? (Check all that apply) ❑ Sump/Trench Sensors; ❑ Dispenser Containment Sensors. Did you confirm positive shut-down due to leaksngnd sensor failure/disconnection? ❑Yes; ❑No. ❑ Yes ❑ No' For monitoring systems that also serve as tank overfill warning devices, is the overfill warning alarm visible QI N/A and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capacity does the alar trie er? % ❑ yes* 11 No Was any monitoring equipment replaced? If yes, identify specific sensors,probes,or other equipment replaced and list the manufacturer name and model for all re lacement arts in Section E,below. PF1 No Was an s stem software u raded? If es,identif the new version number in Section E,below. No Was liquid found inside any secondary containment systems? (Check all that apply) ❑ Product; ❑ Water. If es,describe causes in Section E,below, • In Section E below,describe how and when these deficiencies were or will be corrected. E. Comments: Monitor panels, on wall in store. Page 3 of this Certification must be completed and attached only if one or more of the following conditions are met: l.) In- tank gauging equipment is used to perform leak detection monitoring; 2.) Line leak detectors arc installed an piping systems; 3.) Completion is required by your local agency that regulates UST systems. r':\LJ4ttt Page 2 06!I1P1-r