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Appendix VI Underground Storage Tank Monitoring System Certification Form 5. MONITORING SYSTEM AND PROGRAMMING A separate Monitoring System Certification Form must be prepared for each control panel Make of Monitoring System Model of Monitoring System Software Version Installed Control Panel Control Panel Veeder Root TLS 350 336.02 Attach the post-certification reports if the Monitoring System is capable of Yes No NA generating either- ® Monitoring System Set-Up ® Alarm History Report All monitoring equipment is operational per manufacturer's specifications? ® ❑ Secondary containment systems are free of damage, debris, or liquid? ® ❑ Are the audible and visual alarms operational? ® ❑ All sensors have been: 1) visually inspected for wiring kinks, breaks and residual ® ❑ ❑ buildup on floats; and 2) tested for functionality and confirmed operational? Are all sensors installed to detect a release at the earliest opportunity in the ® El ❑ secondary containment? The monitoring system setup was reviewed, and proper settings confirmed? ® ❑ ❑ Was the monitoring control panel's backup battery visually inspected, functionally tested, and confirmed operational? ® ❑ ❑ Does the flow of fuel stop at the dispenser if a release is detected in the under- dispenser containment? ® ❑ ❑ Does the turbine automatically shut down if the piping secondary containment monitoring system fails to operate or is electrically disconnected? ® ❑ ❑ Does the turbine automatically shut down if the piping secondary containment monitoring system detects a release? Which sensors initiate positive shutdown? ® ❑ ❑ Check all that apply) ® Sump ® UDC If monitoring system alarms are relayed to a remote monitoring center, is all ❑ ❑ communication equipment operational? Describe all answers marked `No"or "Fail"and proposed remedy in Section 9. List all Monitoring equipment either replaced or repaired in Section 9. Page 2 of 6