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Jul . 2 , 2019 3 : 06PM Donlee Pump Co No . 2195 P . 7 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page $ of c) X114 LINE LEAK DETECTOR TESTING Check this box if Ilse leak detectors {LLD) era NOT installed. (Do not complete this Sedlon) Y N NA Tills section must be completed if LLDs are Installed. Was a leak simulated to verify LLD perfomtance? I(I ❑ ❑ Check ell that s t . Simulated leak rate verified: t� 3 GPH C10. 1 GPH 0.2 GPH Was the1esting apparatus properly calibrated? ® Q ❑ For emergency generator lank systems , does the LLD create an audible and visual alarm when a leak Is detected? ❑ ❑ For mechanical LLbs, does the LLD restrict the flow through the pipe when a teak is detected? ® ❑ ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected? Q For electronic LLDs, does the turbine automatically shut off If any portion of the monitoring system is disabled or disconnected? Q ❑ For electronic LLDs, does the turbine automi shut off if any portion of the monitoring system malfunctions or fails a test? 11 El0 For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and breaks? ❑ d Were all items on the equipment manufacturer's maintenance checklist completed? ® ❑ ❑ Were all LLDs confirllned operational Wthln regulatory requirements? ® O ❑ For anv answer of "N" above describe In section Xlil how and when these issues were or will be corrected. XIII, COMMENTS P XIV. VACUUM l PRESSURE/ HYDROSTATIC MONITORING EQUIPMENT TESTING Check this box If VPH monitoring Is NOT used . (Do not complete this section.) Tills section must be Completed if VPN mor►Itoring Is used to perform leak detection monitoring. System Type (Mark all that apply) ❑ Vacuum ❑ Pressure C1 Hydrostatic Sensor FuncUonallty Interstitial Communication Sensor ID Component(s) Monitored by this Sensor Test . Test ❑ Pass ❑ Fall ❑ Pass ❑ Fall ❑ Pass Q Fall ❑ Pass ❑ Fail CJ Pass ❑ Fall [1 Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail d Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass p Fail j ❑ Pass ❑ Fall ❑ Pass Q Fail ❑ Pass ❑ Fall I] Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fall D Pass p Fail ❑ Pass d Fail ❑ Simulated leak at far ends of the Interstitial space. ❑ Visual Inspection How was interstitial communicall in verined? ❑ Other (Describe the method in seCflon XV below.) CI Gauge Was the vacuum or pressure restored to operating levels in all Interstitial spaces? ❑ Yes Q No (Descrlbe the reason in section XV below.) Foran answer of "PAIL " above describe in secffon XV how and when these issues were or will be corrected. XV. COMMENTS �I