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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page s 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? ❑X ❑ ❑ (Check all that apply.) Simulated leak rate verified : ❑X 3 GPH ❑ 0. 1 GPH ❑ 0.2 GPH Was the testing apparatus properly calibrated? 0 ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected? El El 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 LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected ? ❑ ❑ N For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ ❑ 0 For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? ❑ ❑ 0 Were all Items on the equipment manufacturer's maintenance checklist completed? ❑ ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? For any answer of "M' above, describe in Section Xlll how and when these issues were or will be corrected. XIII . COMMENTS XIV. VACUUM 1 PRESSURE 1 HYDROSTATIC MONITORING EQUIPMENT TESTING ❑X 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 Functionality Interstitial Communication Sensor ID Component(S) Monitored By This Sensor Test Test ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass pFail ❑ 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 ❑ Other Describe the method in section XV below. 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 = VacuumiPressure/Hydrostatic, ID = Identification