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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 5) XII . LINE LEAK DETECTOR TESTING FFOICheck 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? Q ❑ ❑ (Check all that apply.) Simulated leak rate verified : ❑X 3 GPH E] 0. 1 GPH [j 0 . 2 GPH Was the testing apparatus properly calibrated ? 1XI I ❑ ❑ 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? 10 ❑ ❑ 0 For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑ ❑ X 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? ❑ F] 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 Q 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 El Pass El 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.) Section XV how and when these issues were or will be corrected. For any answer of "Fail" above, describe in XV. COMMENTS GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification