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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s of s) 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? 0 17 ❑ (Check all that apply.) Simulated leak rate verified: 0 ,9 GPH ❑ 0. 1 GPH ❑ 0.2 GPH Was the testing apparatus property calibrated? V ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected? ❑ 1 ❑ 0 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 disconnected? ❑ I ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or falls a test? Q ❑ ❑ 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 ? ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? Z ❑ ❑ For any answer of "N" above, describe in Section X111 how and when these issues were or will be corrected. XIIL COMMENTS XIV. VACUUM / PRESSURE I HYDROSTATIC MONITORING EQUIPMENT TESTING ❑ Check this box if VPH monitoring is NOT used . (Do not complete this section.) This section must be completed if VPN monitoring is used to perform leak detection monitoring. System Type (Mark all that apply. ) ® Vacuum ❑ Pressure © Hydrostatic SSensor Functionality Interstitial Communication. ensor ID Component(S) Monitored By This Sensor Test Test S-2 REG VAC PRODUCT Pass ❑ Fail 0 Pass ❑ Fail S -3 REG STP VAC VAPOR Pass ❑ Fail Pass ❑ Fail S4 REG STP VAC VENT [7� Pass ❑ Fail © Pass F'1 Fail S4 PREM VAC PRODUCT ® Pass ❑ Fail © Pass ❑ Fail S-8 PREM VAC VENT Pass ❑ Fail Pass ❑ Fail S- 11 DIESEL VAC PRODUCT ® Pass ❑ Fail Pass ❑ Fail S- 12 DIESEL VAC VENT Pass ❑ Fail Z Pass ❑ Fail ❑ Pass EJ Fall E] Pass E] Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail C ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ Pass F1 Fail ❑ Pass E] Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail How was interstitial communication verified? Simulated Leak at Far Ends of the Interstitial Space ❑ Visual Inspection ( Ej Other (Describe the method in section XV below. ) ❑ Gauge I Was the vacuum or pressure restored to operating levels In all interstitial spaces? WJ Yes ❑ No (Describe the reason in section XV below.) i For any 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 = NotApplicable, VPH = VacuumlPressure/Hydrostatic, ID = Identification t