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RECEIVED Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1, Enc. H MAY 15 2014 I. Results of Vacuum/Pressure Monitoring Equipment Testing This page should be used to document testing and servicing of vacuum and pressure inte EWIRONMEML this form must be included with the Monitoring System Certification Form, which must be lamumqialtl w 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 veeder root Model: vph System Type: ❑ Pressure d1 Vacuum Sensor ID Componcnt(s) Monitored b.N' this Sensor: 87 product 1 Sensor Functionality Test Result: R1 Pass F Fail Interstitial Communication Test Result: W01 Pass 1 Fail 2 Component(s) Monitored by this Sensor: 87 vent ^ Sensor Functionality Test Result: Re Pass 1._I Fail Interstitial Communication Test Result: FF Pass r7 Fail 3 Component(s) Monitored by this Sensor: vapor recovery Sensor Functionality Test Result: r Pass R Fail Interstitial Communication Test Result: FPass I Fail Component(s) Monitored by this Sensor: 91 product 4 Sensor Functionality Test Result: r Pass ❑ Fail Interstitial Communication Test Result: R1 Pass ...... Fail Component(s) Monitored by this Sensor: 91 vent 5 Sensor Functionality Test Result: P Pass ❑ Fail Interstitial Communication Test Result: hel Pass LJ Fail Component(s) Monitored by this Sensor: die product 6 Sensor Functionality Test Result: P Pass ❑ Fail Interstitial Communication Test Result: W1 Pass L Fail Component(s) Monitored by this Sensor:die vent 7 Sensor Functionality Test Result: R1 Pass M Fail Interstitial Communication Test Result: hel Pass LJ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass r Fail Interstitial Communication Test Result: LJ Pass LJ Fail Component(s) Monitored by this Sensor: t--� Sensor Functionality Test Result: IJ^Pass LI Fail Interstitial Communication Test Result: L � Pass Fail Component(s) Monitored by thisr -Sensor: Sensor Functionality Test Result: IJ Pass ❑ Fail Interstitial Communication Test Result: U Pass I I i i I How was interstitial communication verified? � Leak Introduced at Far End of Interstitial Space' r Gauge 1_..J Visual Inspection ❑ Other Describe in Sec. J, below Vacuum was restored to operating levels in all interstitial spaces: rVYes ❑ No (If no, describe in Sec. ],below) i. comments l.nuu cnaracters max. use at sensor. 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. W0: 2316672