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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM XII . LINE LEAK DETECTOR TESTING Y N NA ❑ Check this box if line leak detectors (LLD) are NOT installed . (Do not complete this section.) This section must be completed if LLDs are installed. ❑ ❑ ❑ Was a leak simulated to verify LLD performance? GPH. 1 0 .2 GPH Check all that apply. ) Simulated leak rate verified : [] 3 GPH ❑ 0 ❑ ❑ El El Was the testing apparatus properly calibrated? ■ M Li 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? O ❑❑ ❑ Were all items on the equipment manufacturer' s maintenance checklist completed ? ❑ ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? For an answer of "Al" above, descrihe in section Xlll XIII and COMMENTSes were or will be corrected. Replaced T-4 Diesel Line Lek Detector, originally failed 3gph testing . Retested new LD and passed . WINE liiiiiii NEW WE= 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. pp F1Pressure El Hydrostatic System Type (Mark all that ay )I ❑ Vacuum Sensor Functionality Interstitial Communication Test Test Sensor ID Component(s) Monitored by this Sensor ❑ Pass El Fail F1 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Simulated leak at far ends of the interstitial space . ❑ Visual Inspection How was interstitial communication verified? ❑ Gauge El Other (Describe the method in section XV below.) Was the vacuum or pressure restored to operating levels in all interstitial spaces? El Yes [I No (Describe the reason in section XV below.) For an answer of "FAIL " above, describe in section XV w n " when these sues were or will be corrected. OMMENTS GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification