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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s of 6) XII. LINE LEAK DETECTOR TESTING ❑Check this box if line leak detectors(LLD)are NOT installed.(Do not complete this section) Y N NA This section must be completed if LLDs are installed. Was a leak simulated to verify LLD performance? O ❑ El all that apply.) Simulated leak rale verified Q 3 GPH ❑0 1 GPH ❑0 2 GPH Was the testing apparatus properly calibrated? a ❑ ❑ For emergency generator tank systems,does the LLD create an audible and visual alarm when a leak is detected? ❑ ❑ Q For mechanical LLDs,does the LLD restrict the flow through the pipe when a teak is detected? ❑ ❑ Q For electronic LLDs,does the turbine automatically shut off when a leak is detected? Q I ❑ ❑ For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑X 1 ❑ ❑ For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a lest? xEl ::1For electronic LLDs,have all accessible wiring connections been visually inspected for kinks and breaks? XElElWere all items on the equipment manufacturer's maintenance checklist completed? 0 ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? —4❑ I ❑ ❑ For any answer of"N"above,describe in Section X111 how and when these issues were or will be corrected. XIII. COMMENTS XIV. VACUUM/PRESSURE 1 HYDROSTATIC MONITORING EQUIPMENT TESTING ❑ Check this box if VPH monitoring is NOT used. (Do not complete this section) This section must be completed if VPN monitoring is used to perform leak detection monitoring. System Type(Mark all that apply.) ❑Vacuum ❑Pressure ❑X Hydrostatic Sensor lD Component(S)Monitored By This Sensor Sensor Functionality Interstitial Communication Test Test S7 87 Product Vac Q Pass__o Fail Q Pass ❑Fail S9 87 Vent Vac X Pass ❑Fail ❑X Pass Fail S10 Vapor Liner Q Pass ❑Fail Q Pass ❑Fail 511 91 Product X Pass ❑Fail 0 Pass ❑Fail S12 91 Vent ❑X Pass ❑Fail 0 Pass ❑Fail 513 Diesel Product 0 Pass ❑Fail Q Pass ❑Fail S14 Diesel Vent Q Pass ❑Fail X Pass ❑Fail L1 Disp 1-2 ❑Pass ❑Fail ❑Pass ❑Fail L2 Disp 3-4 ❑Pass ❑Fail ❑Pass ❑Fail 1-3 Disp 5.6 ❑Pass ❑Fail ❑Pass ❑Fail L4 Disp 7-8 ❑Pass ❑Fail ❑Pass ❑Fail LS 187 STP ❑Pass ❑Fail ❑Pass ❑Fail How was interstitial communication verified? ❑X Simulated Leak at Far Ends of the Interst tial Space Q Visual inspection Other(Describe the method in section XV bolow) ❑Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? 0 Yes ❑ No(Describe the reason in section XV below) For any answer of"Fail'above,describe in Section XV how and when these issues were or will be corrected. XV. COMMENTS GPH=Gallons Per Hour.Y=Yes,N=No NA=Not Applicable,VPH=VaaauritPressurehiydrostatic.ID=Identification