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RECEIVE® <br />F. In -Tank Gauging / SIR Equipment: P Check this box if tank gauging is used only for inventory control. <br />r Check this box if no tank gauging or SIR equ$i&k2 *IK <br />This section must be completed if in -tank gauging equipment is used to perform leak detection monitoring. <br />Complete the following checklist: <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />• Yes <br />�' No* <br />Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />• Yes <br />�' No* <br />Were all tank gauging probes visually inspected for damage and residue buildup? <br />• Yes <br />f' No* <br />Was accuracy of system product level readings tested? <br />• Yes <br />f No* <br />Was accuracy of system water level readings tested? <br />• Yes <br />No* <br />Were all probes reinstalled properly? <br />• Yes <br />r No* <br />1were 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): r Check this box if LLDs are not installed. <br />Complete the following checklist: <br />+ Yes <br />�' No* <br />For equipment start-up or annual equipment certification was a leak simulated to verify LLD performance? (Check all that <br />� <br />�• N/A <br />apply) Simulated leak rate: P 3 g.p.h.; r 0.1 g.p.h; 0.2 g.p.h. <br />• Yes <br />i No* <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />• Yes <br />i' No* <br />Was the testing apparatus properly calibrated? <br />• Yes <br />�' No* <br />For mechanical LLDs, does the LLD restrict product flow if it detects a leak? <br />K' N/A <br />Yes <br />�' No* <br />For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? <br />i+ N/A <br />Yes <br />ti' No* <br />For electronic LLDs that are programmed for positive shut down, does the turbine automatically shut off if any portion of the <br />G' N/A <br />monitoring system is disabled or disconnected? <br />Yes <br />(' No* <br />For electronic LLDs that are programmed for positive shut down, does the turbine automatically shut off if any portion of the <br />G- N/A <br />monitoring system malfunctions or fails a test? <br />Yes <br />i' No* <br />For electronic LLDs, have all accessible wiring connections been visually inspected? <br />G N/A <br />+ Yes <br />(_ No* <br />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 />Page 3 of 3 12/07 <br />