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nitoring System Certification <br />Site Address: 1103 S. MAIN ST. Date of Testing/Service: 02/03/2009 <br />F. In -Tank Gauging / SIR Equipment <br />Check this box if tank gauging is used only for inventory control. <br />❑ Check this box if no tank gauging or SIR equipment is installed. <br />Check this box if no tank gauging or SIR equipment is installed. <br />This section must be completed if in -tank gauging equipment is used to perform leak detection monitoring. <br />Complete the following checklist: <br />Yes <br />❑ No * <br />Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br />❑ Yes <br />❑ No' <br />Were all tank gauging probes visually inspected for damage and residue buildup? <br />❑ Yes <br />❑No. <br />Was accuracy of system product level readings tested? <br />❑Yes <br />❑No' <br />Was accuracy of system water level readings tested? <br />Yes <br />FjNo' <br />Were all probes reinstalled properly? <br />❑ Yes <br />❑No • <br />Were all items on the equipment manufacturers' maintenance checklist completed? <br />' In the Section H, below, describe how and when these deticiencies were or will be corrected. <br />G. Line Leak Detectors (LLD) : ❑ Check this box if LLDs are not installed. <br />Complete the following checklist: <br />® Yes <br />❑ No <br />❑N/A <br />For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? <br />(Check all that apply) Simulated leak rate: ® 3 g.p.h ❑ 0.1 g.p.h ❑0.2 g.p.h <br />x Yes <br />❑ No <br />Were all LLDs confirmed operational and accurate within regulatory requirements? <br />FX -1 Yes <br />❑ No' <br />Was the testing apparatus properly calibrated? <br />❑ Yes <br />❑ No' <br />❑x N/A <br />For mechanical LLDs, does the LLD restrict product flow if it detects a leak? <br />Q Yes <br />❑No' <br />❑ N/A <br />For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? <br />Q Yes <br />❑No' <br />❑ N/A <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? <br />M Yes <br />❑No' <br />❑ N/A <br />For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? <br />❑x Yes <br />❑No • <br />❑ N/A <br />For electronic LLDs, have all accessible wiring connections been visually inspected? <br />LIJ Yes <br />I ❑No' <br />Were all items on the equipment manufacturers' maintenance checklist completed? <br />. In the Section H, below, describe how and when these deticiencies were or will be corrected. <br />H. Comments: <br />Page 3 of 3 Based on CA form dated 03/01 <br />