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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) 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? R ❑ ❑ (Check all that apply.) Simulated leak rate verified : ❑X 3 GPH ❑ 0 . 1 GPH ❑ 0 .2 GPH Was the testing apparatus properly calibrated? X ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? ❑ ❑ XQ For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected ? ❑ ❑ Q For electronic LLDs , does the turbine automatically shut off when a leak is detected? ❑X ❑ ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected ? 0 ❑ ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? X ❑ 1 ❑ For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? ❑X ❑ ❑ Were all items on the equipment manufacturer's maintenance checklist completed? 0 ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? Z ❑ ❑ For any answer of "M' above, describe in Section XIII how and when these issues were or will be corrected. X111 . COMMENTS XIV. 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.) QX Vacuum ❑ Pressure ❑ Hydrostatic Sensor ID Component(S) Monitored By This Sensor Sensor Functionality Interstitial Communication Test Test S1 87 Product ® Pass ❑ Fail ® Pass ❑ Fail S2 87 Vent ❑X Pass ❑ Fail ® Pass ❑ Fail S3 Vapor Return ❑X Pass ❑ Fail ® Pass ❑ Fail S4 Diesel Product ❑X Pass ❑ Fail ® Pass ❑ Fail S5 Diesel Vent ❑X Pass ❑ Fail ® Pass ❑ Fail S6 91 Product ® Pass ❑ Fail ® Pass ❑ Fail S7 91 Vent ❑X Pass ❑ Fail ❑X Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail j ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail [ ❑ Pass ❑ Fail ❑ Pass ❑ Fail I How was interstitial communication verified ? ® Simulated Leak at Far Ends of the Interstitial Space ❑ Visual Inspection ❑ Other (Describe the method in section XV below.) ❑ Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? ❑X 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 GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification I' 'r r