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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 5 of 6) <br /> X112 LINE LEAK DETECTOR TESTING <br /> El Check this box if line leak detectors (LLD) are NOT installed , (Do not complete this section.) y N NA <br /> This section must be completed if LLDs are installed. <br /> Was a leak simulated to verify LLD performance? <br /> (Check all that apply,) Simulated leak rate verified : [9 3 GPH E] 0 . 1 GPH 0 . 2 GPH <br /> Was the testing apparatus properly calibrated? X Ell El <br /> For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? F] El 21 <br /> For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected ? X El El <br /> For electronic LLDs , does the turbine automatically shut off when a leak is detected? VE11 EEI x <br /> For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected ? El X <br /> For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? Ell Z <br /> For electronic LLDs , have all accessible Wring connections been visually inspected for kinks and breaks? <br /> Were all items on the equipment manufacturer's maintenance checklist completed? X El El <br /> Were all LLDs confirmed operational within regulatory requirements? fl El El <br /> For any answer of "N" above, describe in Section X111 how and when these issues were or will be corrected. <br /> X1110 COMMENTS <br /> XIV. VACUUM I PRESSURE HYDROSTATIC MONITORING EQUIPMENT TESTING <br /> FX Check this box if VPH monitoring is NOT used , (Do not complete this section,) <br /> This section must be completed if VPH monitoring is used to perform leak detection monitoring. <br /> System Type (Mark all that apply.) 0 vacuum El Pressure Hydrostatic <br /> SensorlD Component(S) Monitored By This Sensor Sensor Functionality Interstitial Communication <br /> Test Test <br /> El Pass [:1 Fail 0 Pass E] Fail <br /> [:] Pass El Fail Ej Pass [:1 Fail <br /> El Pass Fail El Pass E] Fail <br /> El Pass [:1 Fail El Pass E] Fail <br /> El Pass El Fail El Pass [:1 Fail <br /> El Pass [:] Fail El Pass El Fail <br /> El Pass [:1 Fail El Pass Ej Fail <br /> El Pass Ej Fail El Pass [:] Fail <br /> El Pass [:1 Fail Ej Pass [:1 Fail <br /> El Pass E] Fail El Pass Fail <br /> El Pass Fail El Pass Fail <br /> [:1 Pass Fail [:1 Pass Fail <br /> How was interstitial communication verified ? F] Simulated Leak at Far Ends of the Interstitial Space El visual inspection <br /> 0 Other (Describe the method in section XV below) [:] Gauge <br /> Was the vacuum or pressure restored to operating levels in all interstitial spaces? El Yes [:] No (Describe the reason in section XV belowj <br /> For any answer of "Fail" above, describe in Section XV how and when these issues were or will be corrected. <br /> XVW COMMENTS <br /> GPH Gallons Per Hour, Y Yes, N No, NA � Not Applicable, VPH Vacuum/Pressureftdrostabc, ID Identification <br />