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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) Xi14 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? ❑ El El Check ail that a ! . Simulated leak rate verified : P4P ❑ 3 GPH 0. 1 GPM El 0. 2 GPH Was the testing apparatus properly calibrated? El El ❑^ 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? El El El 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 lest? El 1771 El For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? 1:1 11 El Were ali items on the equipment manufacturer's maintenance checklist completed ? El ❑ El Were all LLDs confirmed operational within regulatory requirements? ❑ El ❑ For any answer of "N" above, describe In section XIII how and when these issues were or will be corrected. XIII . COMMENTS XIV , VACUUM I PRESSURE/ HYDROSTATIC MONITORING EQUIPMENT TESTING Lj Check this box if VPH monitoring is NOT used . (Do not complete this section.) I This section must be completed If VPH monitoring is used to perform leak detection monitoring, i System Type (Mark all that apply. ) Cl Vacuum ❑ Pressure ❑ Hydrostatic Sensor Functionality Interstitial Communication Sensor ID Component(s) Monitored by this Sensor FTest Test ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail I ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail _ ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail How was interstitial communication verified? ❑ Simuiated leak at far ends of the Interstitial space. El Visual Inspection El Other (Describe the method in section XV below.) [I Gauge Was the vacuum or pressure restored to operating levels In all interstitial spaces? ❑ Yes El No (Describe the reason In section XV below.) Foran 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 a Vacuum/Pressu "ydrostatic, 10 = idenitflcation