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;Momtormg System Certification <br />Site Address: or fobI.)f'I'esting/Servicing: ;Z_ <br />F. In -Tank Gauging / .SIR F,quipenent: ❑ Check this box if tank gauging is used only for inventory control. <br />U Check this box if no tank gauging or SIR equipment is installed. <br />This section trust be completed if in -tank gauging equipntertt is used to perform leak detection monitoring. <br />Complete the following checklist: <br />❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? <br />❑ Yes <br />I O <br />No* <br />Was accuracy of system product level readings tested? <br />❑ Yes <br />❑ <br />No* <br />Was accuracy of system water level readings tested? <br />❑ Yes <br />❑ <br />No* <br />Were all probes reinstalled properly'? <br />❑ Yes <br />O <br />No* <br />Were all items on the equipment manufacturer'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 LLI)s are not installed. <br />Complete the following checklist: <br />Yes <br />❑ No* <br />For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? <br />❑ N/A <br />(Check a// that app/t,) Simulated leak rate: g.p.h., ❑ 0.1 9 -p -h , ❑ 0.2 g.p.h. <br />❑ yo <br />No* <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />s <br />❑ No* <br />Was the testing apparatus properly calibrated? <br />Yes <br />❑ No* <br />For mechanical LLDs, does the LLD restrict product flow if it detects a leak? <br />❑ N/A <br />❑ Yes <br />• <br />❑ NN°* <br />C�' N/A <br />For electronic LLDs, does the turbine automatically shut off if the L.L,D detects a leak? <br />❑ Yes <br />❑ No* <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled. <br />E. N/A <br />or disconnected? <br />❑ Yes <br />❑ No* <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system <br />N/A <br />malfunctions or fails a test? <br />❑ Yes <br />❑ o* <br />Lf N/A <br />For electronic LLDs, have all accessible wiring connections been visually inspected? <br />Yes ❑ No* <br />Were all items on the equipment manuf'acturer's maintenance checklist completed? <br />* In the Section H. <br />below. describe how nna w"h..l, 111— ,r..r..........e...... ..- 2._ <br />H. Comments: <br />Page, 3 of 3 05100 <br />