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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 5 of XII. LINE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors (LLD) are NOT installed. (Do not complete this section.) This section must be completed if LLDs are installed. GPH =Gallons Per Hour, Y = Yes, N = No, NA =Not Applicable, VPH = Vacuum/Pressure/Hydrostatic, ID =Identificati Y N NA Was a leak simulated to verify LLD performance? all that apply.) Simulated leak rate verified: 3 GPH ❑ 0.1 GPH ❑ 0.2 GPH ® ❑ El Was the testing apparatus properly calibrated? ® ❑El For emergency generator tank systems, does the LLD create an audible and visual alarm when a leak is detected?El 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? 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? ❑ 21 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 RECEIVED MAY 18 %0':3 ENVIRONMENTAL HEALTH DFRARTNAENT 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 Test Interstitial Communication Test ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail I ❑ 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 p ❑ Other (Describe the method in section XV below.) ❑Visual ❑ Gauge Inspection 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 on