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12/01/2005 12:17 16613637474 CHAMPION PT INC PAGE 07 <br /> Site Address: Date of Tosting/Servicing: <br /> F. In-frank Gauging/SIR lEquiPPIC"t: ❑ Check this box if tank gauging is used only for iuve»tory control- <br /> [3 Check this box if no tank gauog or SIR.equipmont is.installed.. <br /> This section must be completed if in-tank ganging equipment is used to perform,leak detection monitoring. <br /> Co )lets the t411o•vin <br /> * whin been in fol proper 9%Uy and termination,incl testing for ground tltn1W. <br /> L�YeS D No Has alt input g <br /> Yes ® No* Were,all tank gauging probes visually inspected for damage and residue buildup? <br /> [8'Yes ❑ No* Was=mcyA Wsmm product Level heading$tested? <br /> ff Yes p No* Was.accuracy of system water levet readings tested? <br /> g!ryes ❑ No* were all probes reinstalled properly? <br /> zr Yes Wcrc all items on the egnipment cb='s vWntCBaM0e checkUst completed? <br /> In the Section H,below,,describe how and when these denciencies were or wr'Ll be corrected <br /> G. line Leak Detector!t(LLD): ❑ Check this box if LLDs are not iunstalled_ <br /> Com lets the ft�llorvin ebeeldim: <br /> ( 'es p No* For. equipment start up or equi certification, was a leak simulated to verify LLD performance? <br /> ❑ NIA (Check all that apply) Simulated leak rate: &I. g.p.L'; a 0.1 g.p.ha; ❑{1.2 g.p.1t Z <br /> Notes, 1. L�uired for equipment start-up certifiication and annual ceztifc ation. <br /> 2. Unless by local agency,certification required only for Electronic LLD start-uUrYp. <br /> es ❑ No* Were all LLDs rived 'o aecurat�c witbxn. ory rements? <br /> es ❑ No* Was the testing properly calibrated? <br /> 'ya Q No* For m� 'cal.LLDs,does the LLD restrict product How if it detects a leak? <br /> d NIA. <br /> C3 Yes ❑ N®* For electronic LLDs,does the turbine autowaticathy shat off if the LLDdetects <br /> a leak? <br /> i(N/A <br /> p Yes ❑ No* For electronic LLI)s,does the turbine automatically strut off if arty portion of the�atontitoring systx;nt 9s disabled <br /> M-NIA or ' ectcd? <br /> U Yes ® No* For elcem mic LLDs, does the hubine automatically shut off if arty portion of the amonitoring system <br /> LYN/A ons or fails a test? <br /> Q Yep ❑ No* For.electronic LLDs,have all accessible wiling connecdoms been visually i. ected? <br /> VYN/A <br /> rya ❑ No* were all items(in the equipment m ft 's maintenance chexktist completed? <br /> *In the Section 11,below,describe how and when deficiendes were or will be corrected. <br /> JEi Comments: <br /> Pate 3 of 3 03MIL <br />