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Oonitoring System Certification 01 <br /> Site Address: 1234 YOSEMITE AVE Date of Testing/Service: 06/28/2001 <br /> F. In-Tank Gauging / SIR Equipment ❑ 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 /> This section must be completed if in tank gauging equipment is used to preform 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 ❑No* Was the accuracy of system product level readings tested? <br /> ®Yes ❑No* Was accuracy of system water level readings tested? <br /> ® Yes F_�No* Were all probes reinstalled properly? <br /> ® Yes I ❑No* Were all items on the equipment manufacturer's maintenance checklist completed? <br /> G. Line Leak Detectors (LLD) : ❑ Check this box if no tank gauging or SIR equipment is installed. <br /> Complete the following checklist: <br /> For equipment s a -up or annual equipment certification,was a leak simulated to verify performance? <br /> ® Yes ❑No* ❑N/A (Check all that apply)Simulated leak rate:®3 g.p.h❑0.1 g.p.h ❑0.2 g.p.h <br /> ® Yes ❑No* Were all LLDs confirmed operational and accurate within regulatory requirements? <br /> © Yes ❑No* Was the testing apparatus properly calibrated? <br /> ©Yes ❑No* ® N/A For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> ❑Yes [:]No* ❑ N/A For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? <br /> ©Yes ❑No* ❑ N/A For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected. <br /> El Yes No L1N/A For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test-, <br /> ®Yes ❑No* ❑ N/A or electronic LLDs, have all accessible wiring connections been visually inspected? <br /> ®Yes ❑No VVere 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 /> H. Comments: <br /> page 3 of 3 <br />