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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s of s) XII . LINE LEAK DETECTOR TESTING N 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 apply. Simulated leak rate verified : ❑ 3 GPH ❑ 0 . 1 GPH ❑ 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 ? ❑ ❑ ❑ 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 ? ❑ ❑ ❑ 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 requirements? ❑ ❑ ❑ For any answer of "N" above, describe in section Xlll how and when these issues were or will be corrected. XIII . COMMENTS The PLLDIs are in the lower console . 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. ) N Vacuum ❑ Pressure N Hydrostatic Sensor Functionality Interstitial Communication Sensor ID Component(s) Monitored by this Sensor Test Test L1 , 2 , 3 ,4 87A, 8713 , 91 , UNLEADED ADDITIVE ANNULARS N Pass ❑ Fail N Pass ❑ Fail L22- L33 DISPENSER 01 -24 HYDRO SENSOR N Pass ❑ Fail N Pass ❑ Fail L34 87A FILL HYDRO N Pass ❑ Fail N Pass ❑ Fail L35 87A STP HYDRO N Pass ❑ Fail N Pass ❑ Fail L36 87B FILL HYDRO N Pass ❑ Fail N Pass ❑ Fail L37 87B STP HYDRO N Pass ❑ Fail N Pass ❑ Fail L38 91 FILL HYDRO N Pass ❑ Fail N Pass ❑ Fail L39 91 STP HYDRO N Pass ❑ Fail N Pass ❑ Fail L40 UNLEADED ADDITIVE HYDRO N Pass ❑ Fail N Pass ❑ Fail L41 UNLEADED ADDITIVE VENT HYDRO N Pass ❑ Fail N Pass ❑ Fail L42 UNLEADED VENT HYDRO N Pass ❑ Fail N Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail How was interstitial communication verified ? N Simulated leak at far ends of the interstitial space . N Visual Inspection ❑ Other (Describe the method in section XV below.) ❑ Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? N 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