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Site Address: Date of Testing/Servicing: <br /> F. In-Tank Gauging/SIR Equipment: ❑ Check this box if tank gauging is used only for inventory control. <br /> ❑ Check this box if no tank gauging or SIR equipment is installed. <br /> This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. <br /> _-Complete the folkiwing checklist: <br /> I <br /> es ❑ No* Has all inputfor proper entry and termination, including testing for ground faults? <br /> es ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? <br /> ,Yes O No* Wasaccuracy of system product level readings tested? <br /> es O No* Was accuracy of system water level readings tested? <br /> Yes ❑ No* Were all probes reinstalled properly? <br /> Yes ❑ No* Were all items on the equipment mamr actt=,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): ❑ Check this box if LLDs are not installed. <br /> Com fete the followin checklist• <br /> Yes ❑ No* For equipment start-up or annual equipment cation, was a leak simulated to verify LLD performance? <br /> ❑ N/A (Check all that apply) Simulated teak rate: 3 g.p.h.'; ❑0.1 g.p.h.Z; [10.2 h. <br /> Notes: i. g•p• z <br /> for equipment start-up certification and annual certification. <br /> 2. Unless mandated by local agency,certification required only for electronic LLD start-up. <br /> Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? <br /> es ❑ No* Was the testing apparatus properly calibrated? <br /> Yes O No* For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> ❑ N/A <br /> ❑ Yes ❑ leo* For el <br /> ettmnic LLDs, does the turbine automatically shut off if the LLD detects a leak? <br /> O`N/A <br /> C] Yes ❑ No* For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled <br /> D'N/A or disconnected? <br /> ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitorinsstem <br /> ly N/A maifbnctions or fails a test? ring <br /> ❑ Yes all accessible wiring connections been visualY inspected? <br /> l <br /> /�` �N/A <br /> CrYes ❑ No* Were all items on the equipment manufacturers <br /> 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 <br /> 03/01 <br />