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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1, Enc. lI I. Results of Vacuum/Pressure Monitoring Equipment Testing This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of this form must be included with the Monitoring System Certification Form, which must be provided to the tank system owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form to the local agency regulating UST systems within 30 days of test date. Manufacturer. veederoot Vludcl: »5l S�stcmfv u: Prc.<ur� . I �� b'acuwn Sensor ID S-3 Component(s) Monitored by this Sensor: 91 Prod Sensor Functionality Test Result: WOPass r, Fail Interstitial Communication Test Result: V Pass r Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass Fail Interstitial Communication Test Result: r Pass I. : Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass r Fail Interstitial Communication Test Result: r Pass F Fail Component(s) Monitored by this Sensor: I Fail Sensor Functionality Test Result: Pass r Interstitial Communication Test Result: Pass Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass r Fail Interstitial Communication Test Result Pass Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass r Fail Interstitial Communication Test Result: Pass Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass r Fail Interstitial Communication Test Result: Pass i I ail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass r Fail Interstitial Communication Test Result: r Pass r Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass r Fail Interstitial Communication Test Result: Pass Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass r Fail Interstitial Communication Test Result: Pass Fail How was interstitial communication verified? Leak Introduced at Far End of Interstitial Spacel r Gauge PO' Inspection r Other Describe in Sec. J, below Vacuum was restored to operating levels in all interstitial spaces: P Yes r No (If no, describe in Sec. 3, below) J. Comments 500 characters max. use additional sheets if needed): Page 4 of 4 I If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. WO: 2318135