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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM 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? El ❑ ❑ Check all that apply,) Simulated leak rate verified : El 3 GPH ❑ 0 . 1 GPH ❑ 0 .2 GPH Was the testing apparatus properly calibrated? El ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? E ❑ ❑ 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 ? r0E) E01 n For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? ❑ E For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ [i]For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? ❑ 0Were all items on the equipment manufacturer's maintenance checklist completed? ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? [i] ❑ ❑ 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.) I 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 Functionality Interstitial Communication Sensor ID Component(s) Monitored by this Sensor Test Test i ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail How was interstitial communication verified ? ❑ Simulated leak at far ends of the interstitial space . ❑ Visual Inspection ElOther (Describe the method in section XV below.) El 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 = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/PressureMydrostatic, ID = Identification