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R E <br />i <br />.,I V E D <br />Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors MAR 2 9 2017 LG 163-1, Enc. II <br />I. Results of Vacuum/Pressure Monitoring Equipment Testing EI�VIR®T`'" * �' HEALTH <br />This page should be used to document testing and servicing of vacuum anpressure interstitial sgnsors. 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: 330020-463 <br />System Type: r Pressure F= Vacuum <br />Sensor ID <br />Component(s) Monitored by this Sensor: <br />sl <br />87 prod st <br />r <br />P <br />Sensor Functionality Test Result: l� Pass 1 Fail <br />Interstitial Communication Test Result: <br />Pass %0 Fail <br />s2 <br />Component(s) Monitored by this Sensor: <br />87 vent fill <br />r <br />Sensor Functionality Test Result: Pr. Pass Fail <br />Interstitial Communication Test Result: <br />Pass W. Fail <br />3 <br />Component(s) Monitored by this Sensor: <br />yr all udcs <br />Sensor Functionality Test Result: W Pass r Fail <br />Interstitial Communication Test Result: <br />Pass % Fail <br />4 <br />Component(s) Monitored by this Sensor: <br />91 prod stp <br />Sensor Functionality Test Result: Ir Pass r Fail <br />Interstitial Communication Test Result: <br />Pass W. Fail <br />sS <br />Component(s) Monitored by this Sensor: <br />91 vent filldsl prod stp <br />RR r <br />Sensor Functionality Test Result: P. Pass 1 . Fail <br />Interstitial Communication Test Result: <br />Pass IYO Fail <br />6 <br />Component(s) Monitored by this Sensor: <br />dsl rod stp <br />t— <br />Sensor Functionality Test Result: Ir Pass 1 . Fail <br />Interstitial Communication Test Result:F. <br />Pass F. Fail <br />7 <br />Component(s) Monitored by this Sensor: <br />dsl fill vent <br />Sensor Functionality Test Result: FO Pass r Fail <br />Interstitial Communication Test Result: <br />Pass %0 Fail <br />Component(s) Monitored by this Sensor: <br />r <br />Pass Fail <br />Sensor Functionality Test Result: r r <br />Interstitial Communication Test Result: <br />Pass Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: r <br />Pass F Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: I <br />Pass I Fail <br />How was interstitial communication verified? <br />Leak Introduced at Far End of Interstitial Space' r Gau e r Visual Inspection r Other Describe in Sec. J, below <br />Vacuum was restored to operating levels in all interstitial spaces: <br />r Yes r No (If no, describe in Sec. J, below) <br />unable to test communication but passed on functionality <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 />WO: 2330296 <br />