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p4 r5-- 41 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s of 6) 5 1 00 XII . LINE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors (LLD) are NOT installed . (Do not complete this section.) I f M ( Ny l I h K PAI is I This section must be completed if LLDs are installed. r < w. , x R. -• Was a leak simulated to verify LLD performance? F (Check all that apply.) Simulated leak rate verified : ❑X 3 GPH ❑ 0. 1 GPH ❑ 0 . 2 GPH FX1 ❑ ❑ 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 ? ❑ ❑ X❑ For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected? ❑ ❑ X❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected ? QX ❑ ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? FXEl 1:1 For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑X ❑ ❑ 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 El all LLDs confirmed operational within regulatory requirements? QTF ❑ For any answer of "N" above, describe in Section Xlll how and when these issues were or will be corrected. XIII . COMMENTS XIV. VACUUM / PRESSURE / HYDROSTATIC MONITORING EQUIPMENT TESTING ❑X 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 ID Component(S) Monitored By This Sensor Sensor Functionality Interstitial Communication 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 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? ❑ 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