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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors <br />LG 163-1, Enc. 11 <br />I. Results of Vacuum/Pressure Monitoring Equipment Testing <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: credo root <br />Model: rpli <br />S}:ctcm "I Npe: Pressure ry Vicuum <br />Sensor ID <br />I <br />Component(s) Monitored by this Sensor: <br />87 -product <br />Sensor Functionality Test Result: r'O' Pass r Fail <br />Interstitial Communication Test Result: "0 Pass <br />f Fail <br />2 <br />Component(s) Monitored by this Sensor: <br />87 vent <br />Sensor Functionality Test Result: r Pass P Fail <br />Interstitial Communication Test Result: r Pass <br />r Fail <br />i <br />Component(s) Monitored by this Sensor: <br />vapor recovery <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: "O Pass <br />Fail <br />4 <br />Component(s) Monitored by this Sensor: <br />91 product <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: Pass <br />Fail <br />5 <br />Component(s) Monitored by this Sensor: <br />91 vent <br />Sensor Functionality Test Result: rV Pass r Fail <br />Interstitial Communication Test Result: t Pass <br />._.' Fail <br />6 <br />Component(s) Monitored by this Sensor: <br />dsl product <br />Sensor Functionality Test Result: r Pass I Fail <br />Interstitial Communication Test Result: ' Pass <br />I Fail <br />7 <br />Component(s) Monitored by this Sensor: <br />dsl vent <br />Sensor Functionality Test Result: P Pass r Fail <br />Interstitial Communication Test Result: w. Pass <br />rPail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: r Pass <br />r Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: r Pass <br />r Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: Pass <br />Fail <br />How was interstitial communication verified? <br />10' Leak Introduced at Far End of Interstitial Space' r Gauge r Visual Inspection r Other Describe in Sec. J, below <br />Vacuum was restored to operating levels in all interstitial spaces: <br />P Yes r No (If no, describe In Sec J, below) <br />P. t-omments tauu characters max. use aaaitionai sheets it <br />S-2 AND s-6 failed because they would not see high liquid. <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: 2302101 <br />