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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Fuge 8 of 6) X11 . 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? Z ❑ ❑ (Check aft that apply.) Simulated leak rate verified : ❑ 3 GPH - ❑ 0 . 1 GPH ❑ 0.2 GPH Was the testing apparatus properly calibrated? © ❑ I ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? ❑ ❑ I Z 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 ? tZEI 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 ? ❑ 1:1Were all items on the equipment manufacturer's maintenance checklist completed ? El11Were all LLDs confirmed operational within regulatory requirements ? ❑ For any answer of "N" above, describe in Section X1i1 how and when these issues were or will be corrected. XII1 . COMMENTS XIV, VACUUM 1 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 ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ 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 i i GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vamum/PressureJHydrostatic, ID = Identification i 3 1