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C7 Monitoring System Certification - Page 3 of 3 Site Address: 401 W. Kettleman Ln. Date of Testing/Servicing: 2/23/17 F. In - Tank Gauging / SIR Equipment: H Check this box if tank gauging is used only for inventory control. ❑ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in -tank gauging equipment is used to perform leak detection monitoring. Complete the foll ing checklist: ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of system product level readings tested? ❑ Yes ❑ No* Was accuracy of system water level readings tested? ❑ Yes ❑ No* I Were all probes reinstalled properly? ❑ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): ❑ Check this box if LLD's are not installed. Com tete the follo ing checklist: ® Yes ❑ No* For equipment start-up or annual equipment certification was a leak simulated to verify LLD performance? ❑ N/A (Check all that apply) Simulated leak rate: ® 3 g.p.h. (l.); ❑ 0.1 g.p.h. (2.); ❑ 0.2 g.p.h. (2.). Notes: 1. Required for equipment start-up certification and annual certification. 2. Unless mandated by local agency, certification re uired only for electronic LLD start-up. IN Yes ❑ No* Were all LLD's confirmed o erational and accurate within regulatory requirements? ® Yes ❑ No* Was the testing apparatus properly calibrated? ® Yes ❑ No* For mechanical LLD's, does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLD's, does the turbine automatically shut off if the LLD detects a leak? ® N/A ❑ Yes ❑ No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system is disabled ® N/A or disconnected? ❑ Yes ❑ No* For electronic LLD's, does the turbine automatically shut off if any portion of the monitoring system ® N/A malfunctions or fails a test? ❑ Yes ❑ No* For electronic LLD's, have all accessible wiring connections been visually inspected? » N/A ® Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below, describe how and when these deficiencies were or will be corrected. H. Comments: MAR 2 2 2017 ENVIRONMENTAL HEALTH DEPARTMEW