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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6 XII . LINE LEAK DETECTOR TESTING J 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? El El ❑ Check all that a / . Simulated leak rate verified: 3 GPH 0. 1 GPH 0.2 GPH Was the testing apparatus properly c4brated? ❑ ❑ ❑ For emergency generator tank systems does the LLD create an audible and visual alami 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 1s detected? Q ❑ ❑ 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 wiring connections been visually inspected for kinks and breaks? ❑ ❑ ❑ Were all Items on the equipment manufacturer's maintenance checklist completed? ❑ ❑ ❑ Were all LLDs confirmed operational within regulatory regulrements? ❑ ❑ ❑ For any answer of "N" above describe In section X111 how and when these Issues were or will be corrected. XIII . COMMENTS XIV, VACUUM I PRESSURE/ HYDROSTATIC MONITORING EQUIPMENT TESTING DV 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 monftorin_g. System Type (Mark ail thaf apply. ) Vacuum F1 Pressure ❑ Hydrostatic Sensor Functionality Interstitial Communication ..Sensor ID Component(s) Monitored by this Sensor Test Test Pass Q Fail Pass LLFall Pass F1 Fall ELEass Fail Pass Fat Pass Fail D.Eaqss Q Fail PassFail Pass Fall ELPass ELFal Pass FailPass ELFall Pass Q Fail ELPass Fai Pass Fail PassFail Pass n Fail Pass afFgfil Pass El Fail PassFaii Passn Fail El Pass Ej Fall Pass DEd EDEamss Fail How was interstitial communication verified? n Simulated leak at far ends of the interstitial space . ❑ Visual Inspection ❑ Other (Describe the method in sectionXow. ELGauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? Yes I] No (Describe the reason in section XV below. i For any answer of "F IL " above describe In section XV how and when these issues were or will be corrected, XV. COMMENTS I I