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Chevron Station# 208118 MonthNear: Equipment: Veeder-Root TLS -350 Date Equipment Operational? {Green Light On} Alarm Status O.K.? {All functions Normal} Comments 7 Initials 01 Yes ❑ No ❑ Yes ❑ No ❑ "�' � 02 Yes ❑ No ❑ Yes ❑ No ❑ 03 Yes ❑ No ❑ Yes ❑ No ❑ 04 Yes ❑ No ❑ Yes ❑ No ❑ ENVd 0;° �� E N7 AL T77 VH 05 Yes ❑ No ❑ Yes ❑ No ❑ `�� 06 Yes ❑ No ❑ Yes ❑ No ❑ 07 Yes ❑ No ❑ Yes ❑ No ❑ 08 Yes ❑ No ❑ Yes ❑ No ❑ 09 Yes ❑ No ❑ Yes ❑ No ❑ 10 Yes ❑ No ❑ Yes ❑ No ❑ 11 Yes ❑ No ❑ Yes ❑ No ❑ 12 Yes ❑ No ❑ Yes ❑ No ❑ 13 Yes ❑ No ❑ Yes ❑ No ❑ 14 Yes ❑ No ❑ Yes ❑ No ❑ 15 Yes ❑ No ❑ Yes ❑ No ❑ 16 Yes ❑ No ❑ Yes ❑ No ❑ 17 Yes ❑ No ❑ Yes ❑ No ❑ 18 Yes ❑ No ❑ Yes ❑ No ❑ 19 Yes ❑ No ❑ Yes ❑ No ❑ 20 Yes ❑ No ❑ Yes ❑ No ❑ 21 Yes ❑ No ❑ Yes ❑ No ❑ 22 Yes ❑ No ❑ Yes ❑ No ❑ 23 Yes ❑ No ❑ Yes ❑ No ❑ 24 Yes ❑ No ❑ Yes ❑ No ❑ 25 Yes ❑ No ❑ Yes ❑ No ❑ 26 Yes ❑ No ❑ Yes ❑ No ❑ 27 Yes ❑ No ❑ Yes ❑ No ❑ 28 Yes ❑ No ❑ Yes ❑ No ❑ 29 Yes ❑ No ❑ Yes ❑ No ❑ 30 Yes ❑ No ❑ Yes ❑ No ❑ 31 Yes ❑ No ❑ Yes ❑ No ❑ In the case of alarms, (audible alerts, warning and alarm system lights), system failure, tear off the Alarm Condition Report printout from your monitoring system and document the alarm condition under the appropriate category listed above. Using the Suspected Leak Activity Loa, track your activities until "All Functions Normal" is displayed on the monitoring system console. Retain ALL alarm condition reports and repair work orders related to each alarm. O FAX THE FIRST PASSING .1 GPH LINE TEST FOR CALENDAR YEAR TO VEEDER-ROOT WITH COVER SHEET. RETAIN ALL other LINE TEST REPORTS in a file. File this form, Veeder-Root Fax and LINE Test Reports with the UST Inventory Reconciliation Logs in the appropriate month section of your station's Retail Facility Compliance Workbook. Manager Review (Signature) Date: