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UNDERGROUND STORAGE TAN MONITORING SYSTEM CERTIFICATIO I FORM XII , UNE LEAK DETECTOR TESTING F] Check this box if line leak detectors ( LLD) are NOT installed . (Do not complete this section.) Y N N/A This section must be completed if LLDs are installed. Was a leak simulated to verify LLD performance ? N ❑ ❑ (Check all that apply.) Simulated leak rate verified : ® 3 GPH ❑ 0 . 1 GPH ❑ 0 . 2 GPH Was the test apparatus properly calibrated ? ® ❑ ❑ For emergency generator tank systems, does the LLD create an audible and visual alarm when a lea is detected ? ❑ ❑ N For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected? N ❑ ❑ 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 s disabled or ❑ ❑ N disconnected ? For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system alfunctions or fails a ❑ ❑ N test? For electronic LLDs, have all accessible wiring connections been visually inspected for kinks and bre ks ? ❑ ❑ N Were all items on the equipment manufacturer' s maintenance checklist completed ? N ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? ® El El For any answer of "N" above, describe in Section Xlll how and when these issues were or will be ci Prrected. 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 ❑ Hydrostatic Sensor ID Components) Monitored By This Sensor Sens r Functionality Interstitial Test Communication Test ❑ ass ❑ Fail ❑ Pass ❑ Fail ❑ ass ❑ Fail ❑ Pass ❑ Fail ❑ ass ❑ Fail ❑ Pass ❑ Fail ❑ 3ass ❑ Fail ❑ Pass ❑ Fail ❑ ass ❑ Fail ❑ Pass ❑ Fail ❑ ass E] Fail ❑ Pass ❑ Fail ass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Faii ❑ Pass ❑ Fail [❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail 4=:s ❑ Fail ❑ Pass ❑ Fail Fail ❑ PasHow was interstitial communication verified ? ❑ Simulated Leak at Far Ends of the Intace ❑ Visual inspection ❑ Other (Describe the method in Section XVbelow. ) ❑ Gauge For any answer of "Fail" above, describe in Section XV how and when these issues were or will be corrected. XV. COMMENTS