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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? ® D D Check all that apply.) Simulated leak rate verified : ® 3 GPH ❑ 0 . 1 GPH ❑ 0 .2 GPH Was the testing apparatus properly calibrated ? ® D D For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? ❑ D For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected ? ® D ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected ? ® D D 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 test? ® ❑ ❑ For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? ® D ❑ Were all items on the equipment manufacturer's maintenance checklist completed? ® D D Were all LLDs confirmed operational within regulatory requirements? M D ❑ 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 . ) ® Vacuum ❑ Pressure M Hydrostatic Sensor Functionality Interstitial Communication Sensor ID Component(s ) Monitored by this Sensor Test Test S9 87A PRODUCT LINE ® Pass ❑ Fail ® Pass ❑ Fail S10 87A VAPOR LINE ® Pass ❑ Fail ® Pass ❑ Fail S11 87A VENT LINE M Pass ❑ Fail M Pass ❑ Fail S12 87B PRODUCT LINE ® Pass ❑ Fail ® Pass ❑ Fail S13 87B SYPHON LINE ® Pass ❑ Fail ® Pass ❑ Fail S14 87B VENT LINE ® Pass ❑ Fail M Pass ❑ Fail S17 91 PRODUCT LINE ® Pass ❑ Fail ® Pass ❑ Fail S18 91 VENT LINE ® Pass ElFail ® Pass El Fall S19 ADDITIVE PRODUCT LINE ® Pass ❑ Fail ® Pass ❑ Fail S20 ADDITIVE VENT LINE ® Pass ❑ Fail ® Pass ❑ Fail L5 - 11 87A , 8763 91 AND ADDITIVE TANK BRINE SENSORS ® Pass ❑ Fail ® Pass ❑ Fail L15 -22 ALL DISPENSER BRINE SENSORS ® Pass ❑ Fail ® Pass ❑ Fail I How was interstitial communication verified ? ® Simulated leak at far ends of the interstitial space . ® Visual Inspection ❑ Other (Describe the method in section XV below.) D Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? ® 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 GPH o Millnnc npr .hnur. Y = Yee_ N e Nn. NA o Nnt annlirnhip. VPH = Varw im/Praccurn/Hvrirrtctatic in = Iripntifirafinn t