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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s o"6 XII . LINE LEAK DETECTOR TESTING W 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? ❑ ❑ ❑ Check all that a / . Simulated leak rate verified: 3 GPH 0. 1 GPU LU GPH Was the testing apparatus properly calibrated? ❑ ❑ ❑ For emergency generator tank systems does the LLD create an audible and visual alam when a leak is detected? ❑ ❑ ❑ For mechanical LLDs does the LLD restrict the flow through the pipe when a leak Is detected? ❑ ❑ ❑ Rp For electronic LLDs, . does the turbine automatically shut off when a leak Is detected? Ll Ll Ll For electronic LLDs does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? El El El For electronic LLDs does the turbine automatically shut off if any portion of the monitoring system malfuncllons or falls a test? El El ❑ For electronic LLDs have all accessible wiring connections been visually inspected for kinks and breaks? ❑ El ❑ Were all items on the equipment manufacturer's maintenance checklist completed? El El ❑ Were all LLDs confirmed operational within regulatory requirements? ❑ ❑ ❑ For any answer of "N" above describe In section Al how and when these Issues were or will be corrected, X111. COMMENTS i i i I i XIV. VACUUM I PRESSURE/ HYDROSTATIC MONITORING EQUIPMENT TESTING n 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 Functionality Interstitial Communication Sensor ID Component(s) Monitored by this Sensor Test Test Pass Q Fail Pass El Fail Pass 019 PassFail Pass Fail PassFeli Pass Fall El Pass Fai j j Pass Dig Pass Fail Pass Q Fall E Pass EJ.Fall i a- ❑-. ❑- ❑- I Pass Fail Pass Fal Pass Fall El Pass Fail Pass F1 FailPass Q Fail Pass ELFill Ehlamss EI.Fall Pass ELFall PassFail Pass ELFall Pass Mall How was interstitial communication verified? El Simulated leak at far ends of the Interstitial space . ❑ Visual Inspection_ (—( Other (Describe the method In section XV below. ) ELQaue Was the vacuum or pressure restored to operating levels in all interstitial spaces? Yes n No (Describe the reason In section XV below. ) For anv answer of "FAIT_ " above describe In section XV how and when these Issues were or will be corrected. XV. COMMENTS i i i