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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors RECEliVEE)I. Results of Vacuum/Pressure Monitoring q P gE ui ment Testin <br />This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. MAYMI 2015 <br />this form must be included with the Monitoring System Certification Form, which must be provided to the tank <br />system owner/operator. The owner/operator must submit a copy of the Monitoring System Certf$AVj <br />local agency regulating UST systems within 30 days of test date. I.)C7�NTAI_ <br />IT <br />Manufacturcr:veeder root <br />Model: -Ib 1 <br />System Type:r Pressure F :nuum <br />Sensor ID <br />s - I <br />Component(s) Monitored by this Sensor: <br />87prod-stp <br />Sensor Functionality Test Result: P Pass r Fail <br />Interstitial Communication Test Result: 140 Pass r <br />Fail <br />Component(s) Monitored by this Sensor: <br />87 vent -fill <br />s_? <br />Sensor Functionality Test Result: I✓ Pass r Fail <br />Interstitial Communication Test Result: y Pass <br />Fail <br />Component(s) Monitored by this Sensor: <br />yr all udcs <br />Sensor Functionality Test Result: P Pass r Fail <br />Interstitial Communication Test Result: vo Pass r <br />Fail <br />Component(s) Monitored by this Sensor: <br />91 rod -s <br />S -44y <br />r <br />Sensor Functionality Test Result: Pass r Fail <br />Y, <br />Interstitial Communication Test Result: Pass <br />Fail <br />Component(s) Monitored by this Sensor: <br />91 vent -rill <br />Sensor Functionality Test Result: l✓ Pass r Fail <br />Interstitial Communication Test Result: 1VO Pass r <br />Fail <br />Component(s) Monitored by this Sensor: <br />dsl rod-st <br />s -V <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: Pass <br />r Fail <br />Component(s) Monitored by this Sensor: <br />dsl vent -fill -vent <br />s-7 <br />Sensor Functionality Test Result: P Pass r Fail <br />Interstitial Communication Test Result: P Pass I <br />Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: r Pass <br />r Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: I Pass <br />F Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: Pass <br />Fail <br />How was interstitial communication verified? <br />Leak Introduced at Far End of Interstitial Space' r Gauge P Visual Inspection r Other Describe in Sec. J below <br />Vacuum was restored to operating levels in all Interstitial spaces: <br />I✓ Yes r No (If no, describe in Sec. J, below) <br />Page 4 of 4 <br />I If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the <br />sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. <br />WO: 2322112 <br />