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Monitoring System Certification Form: Addendum for Vacuum/Pressuge Interstitial Sensors I. Results of Vacuum/Pressure Monitoring Equipment Testing LG 163-1, Enc. II 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: U fL Model• -i - f7—S-7TU System Type: ❑ Pressure; [Vacuum Sensor ID ./i Component(s) Monitored by this Sensor: % — rp GZ � /-1 r.- �� ' Sensor Functionality Test Result: U41ass; ❑ Fail Interstitial Communication Test Result [ 'ass;. ❑ Fail Component(s) Monitored by this Sensor: V Zvi~ C J V z Sensor Functionality Test Result: [ ass; ❑ Fail Interstitial Communication Test Result: ETass; ❑ Fail SSensor Component(s) Monitored by this Sensor: `� l — (iG,Z— Functionality Test Result: lis; ❑ Fail Interstitial Communication Test Result: [j'Isass; ❑ Fail I- Component(s) Monitored by this Sensor: , Lj !� Sensor Functionality Test Result: EWa--ss; ❑ Fail Interstitial Communication Test Result: ass; ❑ Fail Compongnt(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: El Pass; E] Fail Interstitial Communication Test Result El Pass; ❑Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; E] Fail Interstitial Communication Test Result: ❑Pass; ❑Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: E] Pass; El Fail Interstitial Communication Test Result: ❑Pass; ❑Fail H��ow, jw�as interstitial communication verified? rU� eak Introduced at Far End of interstitial Space;t ❑ Gauge; Visual Inspection; El other (Describe in Sec. J, below Vacuum was restored to operating levels in all interstitial spaces: [�es ❑ No (If no, describe in Sec. J, below) J. Comments: l �S t� � � � -- �T/r�G—+4 CK — >'7 L.t*y' " ,.P- s A -14't a - s t4,'644 f �Jw,4 4 Page / of t uum/pressure leak introduced in the interstitial space at uhe furthest polnL from th,-. If the sensor successfully detects a simulated vac sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice.