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Aug . 30 . 2019 8 . 29AM Donlee Pump Co No . 2568 P . 6 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page'sofs XII , LINE LEAK DETECTOR TESTING Check this box if line task 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 a Simulated leak rale verified. i3GPH 0. 1 GPH ❑ 0.2 GPH Was (lie testing apparatus properly cellbr&ted? ❑ ❑ For emergency generator tank systems, does the LLD 0(e8t0 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 disconnecled? ❑ ❑ 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 manufacturar's maintenance checklist completed? ❑ ❑ Were all LtOs confirmed operational within regulatory' requirements? k ❑ d Fpr an answer of "N" above, describe In section Xll1 how and when !hese Issuos were or wilt 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 seotlon must be completed if VPH monitoring Is used to perform look detection monitoring. System Type (Mark all that apply.) ❑ Vocuum CI Pressure ❑ Hydrostatic Sensor Functionality interstitial Communication Sensor lD Gomponent(s) Monitored by this Sensor Test Test ❑ Pass ❑ Fail ❑ Mass EI Fail ❑ Pass Il Fail ❑ Pass d Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass p Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fall ❑ Pass ❑ Fail d Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail El Pass ❑ Fall ❑ Pass ❑ Fall Q Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass 0 Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Feil Haw was interstitial communication verified? ❑ $Imulaled leak at Far ends of the interstitial sp&re• ❑ Visual Inspection ❑ Other (Describe the method In section XV below.) 0 Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? d Yes ❑ No (Describe the reason in section XV below.) Fur any answer of "FAIL" above, describe in section XV how and when these Issues were or will be corrected, XV. COMMENTS (illi VIRONMENTAL 11 V _ VA. ►Iu ►1.. %IAL1..1 ......L'..mWt % lbU irtenilRrnNnn