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APR 11 2016 <br />Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1, Enc. II <br />NWHONMENTAL <br />I. Results of Vacuum/Pressure Monitoring Equipment Testing n;=p:PTAFI^a.pT <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 464/463 <br />System Type: CEJ Pressure FO,' Vacuum <br />"Model: <br />Sensor ID <br />Component(s) Monitored by this Sensor: <br />s-1 <br />87 rod-st <br />� 1--1 <br />Sensor Functionality Test Result:l±C1 Pass 1_1 Fail <br />Interstitial Communication Test Result: J Pass <br />_i Fai I <br />2 <br />Component(s) Monitored by this Sensor: ---- <br />87 vent -fill <br />Sensor Functionality Test Result: l ' Pass M Fail <br />Interstitial Communication Test Result: U Pass <br />J Fail <br />3 <br />Component(s) Monitored by this Sensor: <br />yr all udc <br />r- <br />Sensor Functionality Test Result: � Pass 1-1 Fail <br />Interstitial Communication Test Result: LJ Pass <br />LJ Fail <br />4 <br />Component(s) Monitored by this Sensor: <br />91 rod-st <br />-� <br />Sensor Functionality Test Result: � Pass 1 __1 Fail <br />Interstitial Communication Test Result: LJ Pass <br />I I Fail <br />s-5 <br />Component(s) Monitored by this Sensor: <br />91 vent -fill <br />�; �; <br />Sensor Functionality Test Result:l!'.] Pass 1_1 Fail <br />Interstitial Communication Test Result: _ Pass <br />J Fail <br />Component(s) Monitored by this Sensor: <br />dsl rod-st <br />s-6 <br />Sensor Functionality Test Result: R Pass rJ Fail <br />Interstitial Communication Test Result: J Pass <br />U Fail <br />Component(s) Monitored by this Sensor: <br />dsl vent -fill <br />s-7 <br />r�-� r—t <br />Sensor Functionality Test Result: 1.'!:l Pass 1_1 Fail <br />Interstitial Communication Test Result: J Pass <br />—. Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result:l-1 11��1 Pass IJ Fail <br />Interstitial Communication Test Result: J Pass <br />J Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: l_1 Pass ❑ Fail <br />Interstitial Communication Test Result: LJ Pass <br />I I a, I <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: M Pass _J1 Fail <br />Interstitial Communication Test Result: LJ Pass <br />J Fail <br />LOW was interstitial communication verified? <br />_I Leak Introduced at Far End of Interstitial Space' VGauge P Visual Inspection <br />r Other Describe in Sec. J, below <br />Vacuum was restored to operating levels in all interstitial spaces: <br />r Yes r No (Ifno, describe in Sec. J, below) <br />Page 4 o' 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: 2326243 <br />