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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM 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? 0 El El Check all that apply,) Simulated leak rate verified : (] 3 GPH [I0 . 1 GPH E] 0 .2 GPH Was the testing apparatus properly calibrated ? � ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected? ❑ ❑ El 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 is detected? r2i] El El For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? El I] For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? El (] For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? El [i)Were all items on the equipment manufacturer's maintenance checklist completed? ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? El ❑ ❑ For any answer of "N" 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.) ❑ Vacuum ❑ Pressure ❑ Hydrostatic Sensor Functionality Interstitial Communication Sensor ID Component(s) Monitored by this Sensor Test Test ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Simulated leak at far ends of the interstitial space . ❑ Visual Inspection How was interstitial communication verified? ❑ Other (Describe the method in section XV below.) ❑ Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? 0 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. i XV. COMMENTS GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/PressurelHydrostatic, ID = Identification