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RECEIVED FF3 2 l 2014 F.In-Tank Gauging/SIR Equipment: 'Check this box if tank gauging is used only for inventory control. Check this box if no tank gauging orMITIMM NTAL This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. HEALTH DEPARTMENT Complete the following checklist: Yes r No* Has all input wiring been inspected for proper entry and termination,including testing for ground faults? Yes r No* Were all tank gauging probes visually inspected for damage and residue buildup? Yes r No* Was accuracy of system product level readings tested? Yes r No* Was accuracy of system water level readings tested? +' Yes No* ere all probes reinstalled properly? Yes Ir No* ere all items on the equipment manufacturer's maintenance checklist completed? *In the Section H,below,describe how and when these deficiencies were or will be corrected. G.Line Leak Detectors(LLD): Check this box if LLDs are not installed. Complete the following checklist: • Yes r No* For equipment start-up or annual equipment certification was a leak simulated to verify LLD performance?(Check all that NA app/y)Simulated leak rate: 3 g.p.h.; 0.1 g.p.h; L 0.2 g.p.h. • Yes r No* Were all LLDs confirmed operational and accurate within regulatory requirements? " Yes r No* Was the testing apparatus properly calibrated? Yes r No* For mechanical LLDs,does the LLD restrict product flow if it detects a leak? +i"+' N/A • Yes r No* For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? "" N/A • Yes r No* For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? N/A + Yes `' No* For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? N/A * Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected? N/A Yes No* 1were all items on the equipment manufacturer's maintenance checklist completed? *In the Section H,below,describe how and when these deficiencies were or will be corrected. H. Comments: Page 3 of 3 12/07