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Underground Storage Tank <br />Monitoring System Certification Form <br />5. MONITORING SYSTEM AND PROGRAMMING <br />A separate Monitoring System Certification Form must be prepared for each control panel. <br />Make of Monitoring System <br />Model of Monitoring System <br />Software Version Installed <br />Control Panel <br />Control Panel <br />Gilbarco <br />EMC <br />127.04 <br />Attach the post -certification reports if the monitoring system is capable of generating <br />Yes <br />No <br />NA <br />either, ® Monitoring System Set-up ® Alarm History Report <br />All monitoring equipment is operational per manufacturer's specifications? <br />P1 <br />97 <br />Secondary containment systems are free of damage, debris, or liquid? <br />F1 <br />ri <br />Are the audible and visual alarms operational? <br />® <br />0 <br />All sensors have been: 1) visually inspected for wiring kinks, breaks and residual <br />Ir <br />r <br />buildup on floats; and 2) tested for functionality and confirmed operational? <br />Are all sensors installed to detect a release at the earliest opportunity in the <br />r <br />17 <br />secondary containment? <br />The monitoring system set-up was reviewed, and proper settings confirmed? <br />IR <br />r <br />Was the monitoring control panel's backup battery visually inspected, functionally <br />FV <br />tested, and confirmed operational? <br />Does the flow of fuel stop at the dispenser if a release is detected in the under- <br />F1 <br />FE] <br />rl <br />dispenser containment? <br />Does the turbine automatically shut down if the piping secondary containment <br />monitoring system fails to operate or is electrically disconnected? <br />Does the turbine automatically shut down if the piping secondary containment <br />monitoring system detects a release? Which sensors initiate positive shut down? <br />Check all that apply) ® Sump ® UDC <br />If monitoring system alarms are relayed to a remote monitoring center, is all <br />communication equipment operational? <br />Describe all answers marked "No" or "Fail" and proposed remedy in Section 9. <br />List all monitoring equipment either replaced or repaired in Section 9 <br />Page 2 of 6 <br />