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Monitoring System Certification - Pap* a f 3 Site Address: 2375 W. Grant Line F. In -Tank Gauging / SIR Equipment: C Date of Testing/Servicing: 05/30/01 x Check this box if tank gauging is used only for inventory control. ❑ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in -tank gauging equipment is used to perform leak detection monitoring. Cmmnlptp the fnllnwina rhprklict- ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of system product level readings tested? ❑ Yes ❑ No* Was accuracy of system water level readings tested? ❑ Yes I ❑ No* I Were all probes reinstalled properly? 11 ❑ Yes I ❑ No* I Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): CAM 1ptp the fnllnwina rhprklict- ❑ Check this box if LLDs are not installed. O Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ❑ N/A (Check all that apply) Simulated leak rate: X 3 g.p.h.'; ❑ 0.1 g.p.h.2; ❑ 0.2 g.p.h.2 Notes: 1. Required for equipment start-up certification and annual certification. 2. Unless mandated by local agency, certification required only for electronic LLD start-up. M Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? ® Yes ❑ No* Was the testing apparatus properly calibrated? ❑ Yes ❑ No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ® N/A ® Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ❑ N/A ® Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ❑ N/A or disconnected? ❑x Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system ❑ N/A malfunctions or fails a test? x❑ Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ❑ N/A [H] Yes ❑ No* I Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. H. Comments: UN -036 - 5/6 http://www.unidocs.org Rev. 08/22/00