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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page 6 of 6) MIN 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? ® ❑ ❑ (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? ❑ ❑ Q For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected? Qr El For electronic LLDs , does the turbine automatically shut off when a leak is detected ? ❑ ZFor electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected ? ElV1For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? E71 For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks ? ❑ ❑ Were all items on the equipment manufacturers maintenance checklist completed? ® El El Were all LLDs confirmed operational within regulatory requirements ? ✓❑ ❑ ❑ For any answer of "N" above, describe in Section X111 how and when these issues were or will be corrected. XIII . 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 SSensor Functionality Interstitial Communication ensor 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 i ❑ Pass [:1 Fail ❑ Pass ❑ Fail E] 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 = VacuunVPressureMydrostatic, ID = Identification I