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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) XII . 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? ❑ ❑ ❑ (Check all that apply.) Simulated leak rate verified : QX 3 GPH ❑ 0 . 1 GPH ❑ 0 . 2 GPH Was the testing apparatus properly calibrated? ❑X ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? ❑ ❑ X❑ For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected ? ❑X ❑ ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected? ❑ ❑ 0 For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected ? ❑ rE X❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ X❑ 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 ? X❑ ❑Were all LLDs confirmed operational within regulatory requirements? 0 ❑ For any answer of "N" above, describe in Section Xlll how and when these issues were or will 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 section must be completed if VPH monitoring is used to perform leak detection monitoring. System Type (Mark all that apply.) ❑X Vacuum ❑ Pressure ❑ Hydrostatic Sensor ID Component(S) Monitored By This Sensor Sensor Functionality Interstitial Communication Test Test S1 87 VENT AND ANNULAR ❑X Pass ❑ Fail ❑X Pass ❑ Fail S2 91 DSL ANNULAR ❑X Pass ❑ Fail ❑X Pass ❑ Fail S3 87 PRODUCT LINE ❑X Pass ❑ Fail ❑X Pass ❑ Fail S4 91 PRODUCT LINE ❑X Pass ❑ Fail Q Pass ❑ Fail S5 DSL PRODUCT LINE ❑X Pass ❑ Fail ❑X Pass ❑ Fail S6 VAPOR RETURN LINE ❑X Pass ❑ Fail ❑X Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail i � El Pass ❑ Fail ❑ Pass E] Fail t ❑ Pass ❑ Fail 1 ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail i ❑ Pass [:1 Fail ❑ Pass ❑ Fail How was interstitial communication verified? ❑X Simulated Leak at Far Ends of the Interstitial Space ❑X Visual Inspection i ❑ Other (Describe the method in section XV below.) ❑X Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? ❑X Yes ❑ No (Describe the reason in section XV below.) For any answer of "Fail' above, describe in Section XV how and when these issues were or will be corrected. XV. COMMENTS R E Cl# SEP ZIJZU ENVIRONMENTAL HEA13H DE [�'PI iT GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification