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Underground Storage Tank <br /> Monitoring System Certification Form <br /> . MONITORING SYSTEM! AND PROGRAMMING <br /> .A separate Monitoring System Certfta don Form mast he prepared for each control panel. <br /> Make of Monitoring System Model of Monitoring System Software Version Installed <br /> Control Panel Gontrol Panel <br /> Veeder-Root TiS_3W 317.02 <br /> Attach the past-certify ation reports rf the monitoring system is capable of generating Yes No FAA <br /> either; © Monitoring System Setup E] Alarm History Report <br /> All monitoring equipment is operational per manufacturer's specifications? © C] <br /> Secondary containment systems are free of damage, debris, or liquid? <br /> Are the audible and visual alarms operational? ® � <br /> All sensors have been: 1) visually inspected for wMng kinks, breaks and residual ® ri <br /> buildup on floats, and ) tested for fun Mortal lty and coOrmed operational? <br /> Are aIt sensors installed to detect a release at the earliest opportunity in the ❑ ❑ <br /> seoondaty oontainment? <br /> The monitoring system set-up was reviewed, and proper settings confirmed? [ <br /> Was the monitoring controi panel's backup battery visually inspected, functionally ® 0 In <br /> tested, and confirmed operational'? <br /> Does the flow of fuel stop at the dispenser If a release is detected In the under ® ri ❑ <br /> dispenser containment? <br /> Does the turbine autornatically shut dawn if the piping secondary containment ® � � ❑ <br /> monitoring system falls 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? © ❑ ' El <br /> check all that apply) 1 Sum UDC <br /> If monitoring syfstern alarms are relayed to a remote monitoring center, Is all ® ® ❑ <br /> communlcabon equipment operational? <br /> Describe all answers marked 'No"or'Fair and proposed remedy in Section 9_ <br /> List all monitoring equipment nrfhermplaced or repaired in Section 9 <br /> Page 2of6 <br />