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Underground Storage Tank Monitoring System Certification Form S. MONITORING SYSTEM AND PROG AMMIN A separate Monitoring System Certification Form must be prepared for each control panel. Nuke of Monitoring System Model of Monitoring System Software Ve€siDn Installed Control Panel Control Panel e ed a r-Root T LS-350 334.00 Attach the post-certification reports if the mon toring system is capable of generating Yes No NA either,, E] Monitoring System Set-up ❑ Alarm History Report All monitoring equipment is operational per manufacturer's specifications? Q ❑ Secondary containment systems are free of damage, debris, or liquid? Q ❑ Are the audible and visual alarms operational? ❑ ❑ All sensors have been: i) visually inspected for wiring kinks, breaks and residual ❑ ❑ � ❑ buildup on floats, and ) tested for functionality and confinned operational? Are all sensors installed to detect a release at the earliest opportunity in the 0 ❑ , ❑ secondary containment? The monitoring system set-up was reviewed, and proper settings confirmed? ® ❑ ❑ Was the monitoring control panel's backup battery visually inspected, functionally ❑ ❑ ❑ tested, and confirmed operational? Dees 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 Lire 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 shut down? � ❑ ❑ � ❑ .(Check all that apply) Fj Sump Fj UDC If monitoring system alarms are relayed to a remote monitoring center, is all ❑ 0 ❑ communication equipment operational? Describe all answers marked "No"or "Fail"and proposed remedy in Section 9. List al/ monitoring equipment either replaced or repaired in Section S Page 2 of 6