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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM 113age s of s► X11. LINE LEAK DETECTOR TESTING ❑X 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? El 1:1 El all that apply.) Simulated leak rate verified: ❑X 3 GPH El 0. 1 GPH El 0. 2 GPH Was the testing apparatus property calibrated? ❑ ❑ ❑ For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected? n0❑ For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected? El ❑ For electronic LLDs, does the turbine automatically shut off when a leak Is detected? ❑ ❑ ❑ For electronic LEDs, does the turbine automatically shut off If any portion of the monitoring system Is disabled or disconnected? ❑ I [] I ❑ 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 manufacturer's maintenance checklist completed? ❑ ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? ❑ ❑ ❑ For any answer of "N" above, describe in Section X111 how and when these Issues were or will be corrected. X111. COMMENTS XIV, VACUUM 1 PRESSURE l HYDROSTATIC MONITORING EQUIPMENT TESTING Q Check this box it VFW 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 ❑ Hydrostatic Sensor ID Component(S) Monitored By This Sensor Sensor Functionality Interstitial Communication Test Test ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ Pass ❑ Fail ❑ Pass ❑ Fail 1 ❑ Pass ❑ Fail ❑ Pass ❑ Fall 1 ❑ Pass ❑ Fail ❑ Pass ❑ Fall I ❑ Pass ❑ Fall ❑ Pass ❑ Fail 1 ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail How was Interstitial communication verified? Simulated Leak at Far Ends of the interstitial Space n Usual Inspection Other Describe the method in section XV below.) Gouge 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 "Fall" above, describe In Section XV how and when these Issues were or will be corrected. XV. COMMENTS i GPH = Galons Per Hour, Y = Yes, N = No, NA = Not ApOcable, VPH = V ID = Identtbcatian I i i