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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 6 of XII. LINE LEAK DETECTOR TESTING kLTH GPH = Gallons Per Hour, Y = Yes, N = No, NA= Not Applicable, VPH = VacwmlPressureJFlydrostaUc, ID = Identification 6) ❑ 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. Y N NA Was a leak simulated to verify LLD performance? (Check all that apply.) Simulated leak rate verified: ❑ 3 GPH ❑ 0.1 GPH ❑ 0.2 GPH ❑ El ❑ Was the testing apparatus properly 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? ❑ ❑ I ❑ 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? ❑ ❑ 1 ❑ For any answer of "N" above, describe In Section Xlll how and when these issues were or will be corrected. XIII: COMMENTS XIV. VACUUM. PRESSURE / HYDROSTATIC MONITORING EQUIPMENT TESTING QX 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.) ❑X Vacuum ❑ Pressure ❑ Hydrostatic Sensor ID Component(S) Monitored By This Sensor Sensor Functionality Test Interstitial Communication Test Remote fill Test port on Secondary - inspected by Stacy Rivera ❑X Pass ❑ Fail ❑ Pass ❑ Fail Product Return Trans Test port on Secondary - inspected by Stacy Rivera ❑X Pass ❑ Fail ❑ Pass ❑ Fail Vent Transition Test port on Secondary - Inspected by Stacy Rivera 0 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ Pass ❑ Fail How was interstitial communication verified? Simulated Leak at Far Ends of the Interstitial Space Other Describe the method In section XV below. 0 ❑ Visual Inspection Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? ❑X 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 b rr d. ,{a XV. COMMENTS ENVIRONM C ? trL I E/