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RECEIVED <br />Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors J u U 4 L J 14LG 163-1, Enc. lI <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 1*tBUXKl Wff&py 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: %ccdcnxv <br />Model: 464 <br />"csU'm I -pc: Pressure 140 Vacuum <br />Sensor ID <br />3 <br />Component(s) Monitored by this Sensor: <br />91 Prod <br />tom- <br />Sensor Functionality Test Result: tom' Pass 1. Fail <br />Interstitial Communication Test Result: 'ePass <br />F Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: W 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 <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 <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 <br />Fail <br />Component(s) Monitored by this Sensor: <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 />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: I-_ 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 <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 <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 <br />I ail <br />How was interstitial communication verified? <br />Leak Introduced at Far End of Interstitial S cet r Gauge P Visual Inspection r Other Describe in Sec. J, below <br />Vacuum was restored to operating levels in all interstitial spaces: <br />1✓ Yes r No (If no, describe in Sec J, below) <br />t ommenrs <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 />W0: 2318135 <br />