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®6frriFa-RrAa kc. GR Job# 1720- 4467 SWRCB,January 2006 F. In-Tank Gauging/SIR Equipment: ❑ Check this box if tank gauging is used only for inventory control. ❑ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Complete the following checklist: Yes ❑ o Has all input wiring been inspected for proper entry and termination,including testing for ground faults? m Yes ❑ No' Were all tank gauging probes visually inspected for damage and residue buildup? Yes ❑ No' Was accuracy of system products level readings tested? m Yes ❑ No' Was accuracy of system water level readings tested? a 'r ❑+ as ❑ No- Were all probes reinstalled properly? Yes ❑ No' Were all items on the equipment manufacturer's maintenance checklist completed? JAN 701 In the Section H,below,describe ow an en Viese e e ene es were 0771 be co . G. Line Leak Detectors(LLD): ❑ Check this box if LLDs are not installed. ENVIRONMENTAL HEALTH Complete the following checklist q1 n"> 77 n r Yes ❑ o or equipment start-up or anrZal equipment certrtication,was a leak simulated verify pe rmance (check a ❑ N/A that apply) Simulated leak rate: 0 3 g.p.h. ❑ 0.1 g.p h ❑ 0.2 g.p.h. ® Yes ❑ No' Were all LLDs confirmed operational and accurate within regulatory requirements? ® Yes ❑ No' Was the testing apparatus property calibrated? ❑ Yes ❑ No' For Mechanical LLDs,does the LLD restrict product flow 0 it detects a leak? ® N/A ® Yes ❑ No' For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? ❑ N/A ® Yes ❑ No- For electronic LLDs,does the turbine automatically shut off d any portion of the monitoring system is disabled or ❑ N/A Disconnected? 0 Yes ❑ No' For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or ❑ N/A fails a test? ® Yes ❑ No' For electronic LLDs,have all accessible wiring connections been visually inspected? ❑ N/A ® Yes ❑ No' 1were all items on the equipment manufacturer's maintenance checklist completed? In the Section H,below,describe how and n these deficiencies were or will be corrected. G. Comments: Monitoring System Certf kation Page 3 of 4 12f07 3