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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of s) XII . LINE LEAK DETECTOR TESTING _ ❑ Check this box if line leak detectors (LLD) are NOT installed. (Do not complete this section.) Y N NA This section must be completed if LLDs are installed. Was a leak simulated to verify LLD performance? © j ❑ ❑ (Check all that apply.) Simulated leak rate verified : © 3 GPH ❑ 0. 1 GPH - ❑ 0.2 GPH Was the testing apparatus properly calibrated ? For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected? �❑ ❑ For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected ? © ❑ ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected ? Li � Li i For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑ ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ ! ❑ For electronic LLDs , have all accessible wring connections been visually inspected for kinks and breaks? ❑ ; ❑ Were all items on the equipment manufacturer's maintenance checklist completed ? 1 ® ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? 1✓ ❑ ❑ For any answer of "N" above, describe In Section Xlll how and when these issues were or will be corrected XIII . COMMENTS — -- -_-- -_ -- j - - -_ _ — __ _ - ---- - -- --XIVo VACUUM VACUUM / PRESSURE ! HYDROSTATIC MONITORING EQUIPMENT TESTING _ Check this box if VPH monitoring is NOT used . (Do not complete this section.) This section must be completed if VPH monitoring is used to perform leak detection monitoring. — System Type (Mark all that apply.) ❑ Vacuum ❑ Pressure ❑ Hydrostatic Sensor ID Component(S) Monitored By This Sensor Sensor Functionality jInterstitial Communication ` Test Test ❑ Pass ❑ Fail j ❑ Pass ❑ Fail ❑ Pass ❑ Fail I [:] Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail -❑ PassF1 Fail _ ❑ Pass ❑ Fail ❑ Pass ❑ Fail E1 ass 0 Fail L] Pass Q Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail .1 ---- - - - ❑ Pass ❑ Fail ❑ Pass ❑ Fail — ❑ Pass ❑_ Fail ❑ Pass ❑ Fail -- -- ( -- --- - -- - -- -- ❑ Pass - ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass Fail How was interstitial communication verified ? ❑ Simulated Leak at Far Ends of the Interstitial Space ❑ Visual Inspection ❑ Other IDescribe the method in section XV below.) ❑ Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? ❑ Yes ❑ No (Describe the reason in section XV below.) For any answer of "Fail' above, describe in Section XV how and when these issues were or will be corrected. XV. COMMENTS i i I i i GPH = Gallons Per Hair, Y = Yes, N = No, NA = Not Applicabie, VPH = VaanAnPressuTeftdrostatic, ID = Identification I E