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Monitoring System Certification • <br /> "Site ilddress: qD44O boar � µ � �'��-f p,, r C-4 Date of Testing/Secvicing: <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 /> COm tete the followio checklist:: <br /> Yes O 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 inspectedfor damage and residue buildup? <br /> ❑ Yes OF 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 properly? <br /> ISI Yes ❑ No* 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 /> G. Ione Leak Detectors(LLD): O'Check this box if LLDs are not installed <br /> Com tete the followin checklist; <br /> Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? <br /> V13No* <br /> (Check all that apply) Simulated leak rate:10 g.pA L; ❑0.1 g p.h; >(0.2 g p h. <br /> 2C Yes Were all LLDs confirmed operational and accurate within regulatory requirements? <br /> a Yes Was the testing apparatus properly calibrated? <br /> Yes For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> ,W Yes For electronic LLD,,does the turbine automatically shut off if the LLD detects a leak? <br /> Yes For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled <br /> or disconnected? <br /> Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of.the monitoring system <br /> JIIF N/A malfunctions or fails a test? <br /> Yes Q No* For electronic LLDs,have all accessible wiring co <br /> PC N/A I <br /> nnections been visually inspected? <br /> 25 Yes ❑ No* Were all items on the equipment maniffacturees maintenance checklist completed? <br /> 'In We Section H,below, describe how and when these deficiencies were or will be corrected, <br /> H. Comments: <br /> Page 3 of 3 05100 <br />