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Underground Storage Tank <br /> Monitoring System Certification Form <br /> A separate Monitori g System Certirrcation Form must be prepared for each control panel. <br /> Make of Monitoring System 1, Model of Monitoring System Software Version Installed <br /> Control Panel Control Panel <br /> Veeder-Root TLS-35OR 336.02 <br /> Attach the post-certification reports if the monitoring system is capable of generating <br /> either,•xMonitoring Sy tem Set-up xAlarm History Report Yes No NA, <br /> All monitoring equipment is operational per manufacturer's specifications? x ❑ <br /> Secondary containment systems arefree of damage, debris, or liquid? x ❑ <br /> Are the audible and visual alarms operational? x ❑ <br /> All sensors have been: 1) visually inspected for wiring kinks, breaks andresiduai buildup on x ❑ Cl <br /> floats; and 2) tested for functionality and confirmed operational? <br /> Are all sensors installed to detect a release at the earliest opportunity in the secondary x ❑ ❑ <br /> containment? <br /> The monitoring system set-up was reviewed,and proper settings confirmed? x ❑ Cl <br /> Was the monitoring control panel's backup battery visually inspected, functionally tested, x ❑ ❑ <br /> and confirmed operational? <br /> Does the flow of fuel c,top at the dispenser if a release is detected in the under-dispenser x ❑ <br /> containment? <br /> Does the turbine autornatically shut down if the piping secondary containment monitoring x <br /> system fails to operate or is electrically disconnected? <br /> Does the turbine auto atically shut down if the piping secondary containment monitoring <br /> system detects a rele se?Which sensors initiate positive shut down? (Check all that x Cl ❑ <br /> apply)xSump xUDC <br /> If monitoring system alarms are relayed to a remote monitoring center, is all communication ❑ ❑ x <br /> equipment operational? <br /> Describe all answer 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 />