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APPENDIX A-3: SAMPLE FORM FOR ANNUAL LEAK DEVICE INSPECTION CHECKLIST <br /> Go to www.pei.argIRP900 for an electronic version of this form. <br /> I D# ANNUAL LEAK DETECTION DEVICE INSPECTION CHECKLIST Date: <br /> Category IDescription PD/RP900 N/ATankt Tank2 Tank3 Tanks <br /> Leak Detection Device. Describe location(e.g., interstitial,.STP,fill,dispenser)on this row: 8.7 <br /> Sensor tested and functional TEST DATE: 8.7.1 <br /> Liquid Sensor Sensor properly mounted at the bottom of the containment sump or pan(containment sump or 8.7.3 <br /> an sensor only) <br /> Sensor properly mounted at the bottom of double-walled tank(double­walled tank sensor only) 8.7.4 <br /> Sensor tested and functional I TEST DATE: 8.7.1 <br /> Discriminating Sensor properly mounted at the bottom of the containment sump or pan(containment sump or 8.73 <br /> Sensor pan sensor only) <br /> Sensor properly mounted at the bottom of double-walled tank(double­walled tank sensor only) 8.7.4 <br /> Hydrostatic Sensor tested and functional TEST DATE: 8.7.1 <br /> Sensor Hydrostatic sensor properly positioned 8.7.5 <br /> Sensor tested and functional TEST DATE: 8.7.1 <br /> Vacuum/Pressure Alarm sounds when pressure or vacuum is released TEST DATE: 8.7.2 <br /> Sensor Entire interstitial space under pressure or vacuum (closed <br /> doublewalletl in system only) TEST DATE: 8.7.7 <br /> Visually <br /> Monitored Leak detection device iswithin recommended limits 8.7.8 <br /> Double-Walled <br /> Sum <br /> Dispenser PanSensor tested and functional TEST DATE: 8.7.1 <br /> Float Mechanism Dispenser pan float mechanism free to move and properly TEST DATE: 8.7.8 <br /> ad'usted <br /> DESCRIBE ANY DEFICIENCIES HERE: <br /> PEI RP 900 Annual Leak Detection Device Inspection Checklist Page_of_ <br />