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Jan . 23 . 2019 7548AM Donlee Pump Co No . 1366 P . 6 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s oto XII . LIFE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors (LLD) are NOT installed. (Do not complete this section.) r( N NA This section must be completed if LLDs are fnstalled. Was a leak simulated to verify LLD performance? ❑ ❑ ❑ Check at/ that apply.) Simulated teak rate verified: ❑ 3 GP H ❑ 0. 1 GPH [10,2 GPH Was the testing apparatus properly calibrated? ❑ ❑ ❑ For emargency generator lank systems , does the LLD create an audible and visual alarm when a leak Is detected? ❑ ❑ ❑ For mechanioal 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? ❑ ❑ a For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? Ij ❑ 0 For electronic LLDs, does the turbine automalloally shut oft if any portion of the monitoring system malfunctions or fails a lest? ❑ ❑ ❑ For electronic LLDs , have all aco6asible wiring connections been visually inspected fol kinks and breaks? ❑ ❑ ❑ Were pill items on the equipment manufacturer's maintenance checklist completed? ❑ ❑ ❑ Were all LLDS confirmed operational within regulatory requirements? ❑ ❑ El For an answer of «N" above, describe in section V11 how and when these issues were or will be corrected. X111 , COMMENTS raft VL{govt : cc>v, NMEt1l� AI XIVw VACUUM l PRESSURE/ HYDROSTATIC MONITORING EQUIN00071 Check lits box if VPH monitoring is NOT used . (Do not complete this seotion.)44 s This section must be completed if VPH mo►tlforing is used to perform leak detection monitoring. System Type (Mark oil that apply.) ❑ Vacuum ❑ Pressure ❑ Hydrostatic Sensor Functionality Interstitial Communication Sensor ID Components) Monitored by this Sensor Test Test 0 Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass 0 Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall i3 Pass d Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Simulated leak at far ends of the interstitial space. Visual inspection How was interstitial communication verified? ❑ other (Descrlbo the method in section XV below.) ❑ Gauge Was the vacuum or pressure restored to operating levels in all Interstitial spaces? ❑ Yes ❑ No (Desoribo the reason in section XV below.) Forany answer of "FAIL" aboVe, describe in section XV how and when these Issues were or will be Corrected XV. COMMENTS !MLWAP Sim nate. .n ' t ' tZnnw !! rzallmwrwrhrrtrY = WA NeNMNA = Nntandlcabte. VPH =V$cuumtPwurdHvdrostaV0. ID = klenHtication