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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page a of 6) XII. LINE LEAK DETECTOR TESTING 11 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? ® ❑ ❑ Check all that a Simulated leak rate verified: ® 3 GPH El 0. 1 GPH ❑ 0.2 GPH Was the testing apparatus property calibrated? ® ❑ ❑ For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak Is detected? ❑ ❑ For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected? ❑ ❑ For electronic LLDs, does the turbine automatically shut off when a leak is detected? ® ❑ ❑ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ® ❑ ❑ For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ® ❑ ❑ For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks? ® ❑ ❑ Were all items on the equipment manufacturer's maintenance checklist completed? ® ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? ® ❑ ❑ 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/ HYDROSTATIC MONITORING EQUIPMENT TESTING ❑ Check this box if VPH monitoring is NOT used . (Do not complete this section.) This section must be completed If VPH monitoring Is used to perform leak detection monitoring. System Type (Mark all that apply.) ® Vacuum ❑ Pressure ❑ Hydrostatic Sensor Functionality Interstitial Communication Sensor ID Component(s) Monitored by this Sensor Test Test S1 87 PRODUCT ® Pass ❑ Fall ® Pass ❑ Fail S2 91 PRODUCT ® Pass ❑ Fail ® Pass ❑ Fail S3 VENTS ® Pass ❑ Fail ® Pass ❑ Fail S4 VAPOR ® Pass ❑ Fail ® Pass ❑ Fall S5 DIESEL PRODUCT ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass [3 Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ` How was interstitial communication verified? ® Simulated leak at far ends of the interstitial space. ❑ Visual Inspection ❑ Other (Describe the method in section XV below.) ❑ Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? I@ 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 APH n r%aunna nar hry cr V a Yr+c N a Nn NA a " annikW4^ VPFt a Vari u muPro*w unrFfvrirnofnfin In c IAwnf f1raf m