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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of B) 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 all that apply ) Simulated leak rate verified: Z 3 GPH El 0. 1 GPH E] 0. 2 GPH Was the testing apparatus properly calibrated ? Q ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? ❑ ✓❑ For mechanical LLDs, does the LLD restrict the flow through the pipe when a leak is detected ? ❑ ❑ W] 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? © ❑ ❑ 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? Q ❑ ❑ Were all items on the equipment manufacturer's maintenance checklist completed? ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? ✓❑ ❑ D For any answer of ` N" above, describe in Section Xlll how and when these issues were or will be corrected. X111v COMMENTS _ E 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 Component(S) Monitored By This Sensor Sensor Functionality Interstitial Communication Test Test S- 1 REGULAR PRODUCT _ ® Pass ❑ Fail 0 Pass ❑ Fail S-2 REGULAR VAPOR © Pass ❑ Fail © Pass ❑ Fail S-3 REGULAR VENT © Pass ❑ Fail © Pass ❑ Fail S4 PREMIUM PRODUCT © Pass ❑ Fail © Pass ❑ Fail S-5 PREMIUM VENT © Pass ❑ Fail Pass ❑ Fail E S-6 DIESEL PRODUCT ©_Pass ❑ Fail W] Pass ❑ Fail S-7 DIESEL VENT © 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 i i i i GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuun/Pressuretdrostatic, ID = Identification i