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Underground Storage Tank <br />Monitoring System Certification Form <br />A separate Monitoring System Certification Form must be prepared for each control panel. <br />Make of Monitoring System <br />Model of Monitoring System <br />Software Version Installed <br />Control Panel <br />Control Panel <br />Veeder-Root <br />TLS -350 <br />16.02 <br />Attach the post -certification reports if the monitoring system is capable of generating <br />either, xMonitoring System Set-up xAlarm History Report <br />Yes <br />No <br />NA <br />All monitoring equipment is operational per manufacturer's specifications? <br />x <br />❑ <br />Secondary containment systems arefree of damage, debris, or liquid? <br />x <br />❑ <br />Are the audible and visual alarms operational? <br />x <br />❑ <br />All sensors have been: 1) visually inspected for wiring kinks, breaks andresidual buildup on <br />x <br />❑ <br />❑ <br />floats; and 2) tested for functionality and confirmed operational? <br />Are all sensors installed to detect a release at the earliest opportunity in the secondary <br />x <br />❑ <br />❑ <br />containment? <br />The monitoring system set-up was reviewed,and proper settings confirmed? <br />x <br />❑ <br />❑ <br />Was the monitoring control panel's backup battery visually inspected, functionally tested, <br />x <br />❑ <br />❑ <br />and confirmed operational? <br />Does the flow of fuel stop at the dispenser if a release is detected in the under -dispenser <br />x <br />❑ <br />containment? <br />Does the turbine automatically shut down if the piping secondary containment monitoring <br />x <br />❑ <br />❑ <br />system fails to operate or is electrically disconnected? <br />Does the turbine automatically shut down if the piping secondary containment monitoring <br />system detects a release?Which sensors initiate positive shut down? (Check all that <br />X <br />❑ <br />❑ <br />apply)xSump xUDC <br />If monitoring system alarms are relayed to a remote monitoring center, is all communication <br />❑ <br />O <br />x <br />equipment operational? <br />Describe all answers marked "No" or "Fail"and proposed remedy in Section 9. <br />List all monitoring equipment either replaced or repaired in Section 9 <br />Page 2 of 6 <br />