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itoring System Certification <br /> Site Address: 1234 YOSEMITE AVE Date of Testing/Service: 05/24/2005 <br /> F. In-Tank Gauging/SIR Equipment Q Check this box if tank gauging is used only for inventory control. <br /> F1 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 /> Q 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 accuracy of system product level readings tested? <br /> Yes R No° Was accuracy of system water level readings tested? <br /> Yes R No° Were all probes reinstalled properly? <br /> ❑Yes ❑No• Were all items on the equipment manufacturers'maintenance checklist completed? <br /> In the Section H,below,describe how and when these deficiencies were or will be corrected. <br /> G. Line Leak Detectors (LLD) : E] Check this box if LLDs are not installed. <br /> Complete the following checklist: <br /> For equipment start-up or annual equipment certification,was a leak simulated to verify LLD performance? <br /> ®Yes ❑No ❑NSA (Check all that apply)Simulated leak rate: 0 3 g.p.h❑0.1 g.p.h E]0.2 g.p.h <br /> X Yes Q No* Were all LLDs confirmed operational and accurate within regulatory requirements? <br /> X YesRNo. Was the testing apparatus properly calibrated? <br /> R Yes ®No• ❑X N/A For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> 0 Yes ❑No- ❑N/A For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? <br /> Q Yes QNo• ❑N/A For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? <br /> a Yes ❑No` ❑N/A For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? <br /> M Yes ❑No" ❑NIA For electronic LLDs,have all accessible wiring connections been visually inspected? <br /> nYes ❑No• Were all items on the equipment manufacturers'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 Based on CA form dated 03/01 <br />