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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors <br />RECEIVEL! <br />APR 3 A M& -c. 11 <br />I. Results of Vacuum/Pressure Monitoring Equipment Testing ENVIRONMENTAL <br />This page should be used to document testing and servicing of vacuum and pressure intersti,(4*jserrs mc6jm yje .T <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 Certification Form to the <br />local agency regulating UST systems within 30 days of test date. <br />Manufacturerveede r nn+i <br />Model:40-I <br />5�.,tcm '1 j pca Prc.,urc <br />CV V'unuun <br />Sensor ID <br />Component(s) Monitored by this Sensor: <br />87prod-stp <br />5-1 <br />Sensor Functionality Test Result: I✓ Pass r Fail <br />Interstitial Communication Test Result: 140 Pass I <br />Fail <br />2 <br />Component(s) Monitored by this Sensor: <br />87 vent -fill <br />Sensor Functionality Test Result: I✓ Pass r Fail <br />Interstitial Communication Test Result: F Pass I <br />Fail <br />3 <br />Component(s) Monitored by this Sensor: <br />yr all udcs <br />Sensor Functionality Test Result: l✓ Pass r Fail <br />Interstitial Communication Test Result: Pass <br />Fail <br />4 <br />Component(s) Monitored by this Sensor: <br />91prod-stp <br />Sensor Functionality Test Result: l✓ Pass r Fail <br />Interstitial Communication Test Result: Pass <br />Fail <br />Component(s) Monitored by this Sensor: <br />91 vent -fill <br />5 <br />Sensor Functionality Test Result: I✓ Pass r Fail <br />Interstitial Communication Test Result: rV; Pass <br />Fail <br />6 <br />Component(s) Monitored by this Sensor: <br />dsl rod-st <br />Sensor Functionality Test Result: 1✓ Pass r Fail <br />Interstitial Communication Test Result V Pass f <br />Fail <br />Component(s) Monitored by this Sensor: <br />dsl vent -fill -vent <br />7 <br />Sensor Functionality Test Result: I✓ Pass r Fail <br />Interstitial Communication Test Result: NO Pass F <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 r <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 f <br />Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: I Pass f <br />Fail <br />How was interstitial communication verified? <br />Leak Introduced at Far End of Interstitial Space' r Gauge P Visual Inspection Other Describe in Sec. J. below <br />Vacuum was restored to operating levels in all interstitial spaces: <br />r Yes r No (If no, describe in Sec. J, below) <br />Page 4 of 4 <br />1 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 />