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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors <br />LG 163-1, Enc. Il <br />I. Results of Vacuum/Pressure Monitoring Equipment Testing <br />This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of <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 />Manufacturer veeder root Model: vph <br />System "Type: r Pressure 1✓ Vacuum <br />Sensor ID <br />Component(s) Monitored by this Sensor: <br />87 product <br />1 <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 />87 vent <br />2 <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: V Pass r <br />Fail <br />3 <br />Component(s) Monitored by this Sensor: <br />vapor recovery <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: Pass r <br />Fail <br />Component(s) Monitored by this Sensor: <br />91 product <br />4 <br />Sensor Functionality Test Result: P Pass r Fail <br />Interstitial Communication Test Result: IV Pass <br />.. Fail <br />Component(s) Monitored by this Sensor: <br />91 vent <br />5 <br />Sensor Functionality Test Result: W Pass r Fail <br />Interstitial Communication Test Result: 1 Pass <br />Fail <br />Component(s) Monitored by this Sensor: <br />die product <br />6 <br />Sensor Functionality Test Result: W Pass r Fail <br />Interstitial Communication Test Result: Pass <br />Fail <br />Component(s) Monitored by this Sensor: <br />die vent <br />7 <br />Sensor Functionality Test Result: 1✓ Pass r Fail <br />Interstitial Communication Test Result: '�'. Pass <br />. -' 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 />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 />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: f Pass r <br />Fail <br />Low was interstitial communication verified? <br />Leak Introduced at Far End of Interstitial Space' r Gauge r Visual Inspection <br />r Other Describe in Sec. J below <br />Vacuum was restored to operating levels in all interstitial spaces: <br />W Yes r No (If no, describe in Sec. J, below) <br />11 lleeueu <br />at sensor. <br />Page 4 al 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: 2316672 <br />