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11/05/2009 THU 8: 48 FAX 9163861256 A Teichert & Son Inc 2003/004 <br /> !`10/28/2009 14:28 66139 3 CHUCK HILL PAGE 03/04 <br /> Adw <br /> c fr7 <br /> Monitoring System Ceirttification <br /> af'. In-Tank Gauging/SIR Equipment: ® 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.must be campleted if in-tank gauging equipment is used to perform leak detection>lnonitot7ng. <br /> Coma fete the followin checklist; <br /> 0 Yes » No* Has all input wiring been inspected for proper entry and.tormination,including testing for ground faults? <br /> ® Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? <br /> 0 Yes ❑ No* Was accuracy of system product level readings tested? <br /> 0 Yes ❑ NO Was accuracy of system water level readings tested? <br /> El Yes ❑ Noy` Were ail proUes reinstalled properly? <br /> M Yes ❑ No* Were all items on the equipment manufacturer's maintenance cmeklist completed? <br /> In the Section It,below,describe how and when these deficiencies were or will be corrected. <br /> G. Line Leak Detectors(.LLD): ❑ Check this box if LLDs are not installed. <br /> Conn let e the followin checklist: <br /> 0 Yes 0 No* For equipment start-up or annual equipment certification, was a. leak simulatccf to verify LLD performance? <br /> Gl N/A (Check all that apply) Simulated leak rate: m 3 g.p.h.; ❑0.1 g.p.h; ❑0.2 g.p.b, <br /> Ll Yes O Noy` Were all LLDs confirmed operational and accurate within regulatory requirements? <br /> o Yes ❑ No* Was the testing apparatus properly calibrated? <br /> ❑ Yes 0 No* For mechanical L.LDs,does the LLD restrict product flow if it detects a leak? <br /> d N/A <br /> ®Yes 13 No* For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? <br /> ® N/A <br /> 0 Yes 0 No* For electronic L.LD9,does the turbine automatically shut off if any portion of the monitoring system is disabled <br /> O N/A or disconnected? <br /> l Yes 0 No* For electronic Li,Ds, doer the turbine automatically shut off if any portion of the monitoring system <br /> ❑ N/A malfunctions or fails a test? <br /> ®Yes ❑ No* For electronic LLDs,have all accessible wiring connections been visually inspected? <br /> C3-N/A <br /> N/A <br /> i-2clYes C3 No* Were all items on the equipment manufacturer's maintenance checklist completed? <br /> *In the Section R belnw,describe how and when these deficiencies were or will be corrected, <br /> H. Comments- <br /> UN-036-3/4 Page 3 of 4 Rev.06/04/01 <br /> wvnvainidocs.org <br />