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Mon0cring System Certification Site Address: //I— auCG�j�, .arf� �- T �_ Dateof'I'esting/Servicing. (5 F. In -Tank Gauging /SIR Equipment: Q"C'(ieck 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 -lank gauging equipment is used to perform leak detection monitoring. Complete the following checklist: ❑ Yes ❑ No* I Has all input wiring been inspected for proper entry and termination, including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of system product level readings tested? ❑ Yes ❑ No* Was accuracy of system water level readings tested? ❑ Yes ❑ No* Were all probes reinstalled properly? ❑ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): ❑ Check this box if LLDs are not installed. Complete the following checklist: ❑'Yes ❑ No* ❑ N/A For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? (Check all that apply) Simulated leak rate: ClT '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 properly calibrated? 2rVes ❑ No* ❑ N/A For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ❑ Yes ❑ No* ❑�1%A For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ❑ Yes ❑ No* p"'? /A For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑ Yes ❑ No* 3-,g q For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ Yes ❑�p*- LSI N/A For electronic LLDs, have all accessible wiring connections been visually inspected? O'Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? III ane 3ecnon n, oeiow, aescrIne now and when these deficiencies were or will be corrected. H. Comments: F`? f � t +E' 4L% ✓�/ k9 t�T t �' ,1`. ` . � i"'O S �fy p -t"0 �OP car 'O'—D h /- Page 3 of 3 05/00