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.-k witcring System Certification • <br /> Date of testing/Servicing: I IOL! <br /> Site Address:�y <br /> F. In-Tank Gauging! SIR Equipment: Teck 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 Icak 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 /> Cl Yes ❑ No* Were all probes reinstalled properly? <br /> ❑ Yes ❑ No* I 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. Line Leak Detectors (LLD): ❑ Check this box if LLDs are not installed. <br /> Complete the following checklist: <br /> Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? <br /> EIN/A (Check all that apply) Simulated leak rate: 3-3 g.p.h.; Ll0.1 g.p.h ; ❑ 0.2 g.p.h. <br /> Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? <br /> Yes ❑ No* Was the testing apparatus properly calibrated? <br /> alVes ❑ No* For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> ElN/A <br /> ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? <br /> ❑ Yes ❑ No* For electronic LLDs, does tite turbine nutomatically shut off if any portion of the monitoring system is disabled <br /> &-OA or disconnected? <br /> ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system <br /> p� /A malfunctions or fails a test? <br /> ❑ Yes ❑ o* For electronic LLDs, have all accessible wiring connections been visually inspected? <br /> l3 N/A <br /> 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 /> H. Comments: <br /> r <br /> Page 3 of 3 05100 <br />