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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: VEEDER ROOT <br />Model: vph <br />mm 'I's pc: r N.."w', <br />;1 uum <br />Sensor ID <br />Component(s) Monitored by this Sensor: <br />F <br />87 product <br />1 <br />Sensor Functionality Test Result: l�' Pass <br />r Fail <br />Interstitial Communication Test Result. Pass r <br />Fail <br />Component(s) Monitored by this Sensor: <br />87 vent <br />Sensor Functionality Test Result: r Pass <br />SO Fail <br />Interstitial Communication Test Result V Pass f <br />Fail <br />3 <br />Component(s) Monitored by this Sensor: <br />vapor recovery <br />Sensor Functionality Test Result: ts' Pass <br />r Fail <br />Interstitial Communication Test Result: Pass <br />Fail <br />4 <br />Component(s) Monitored by this Sensor: <br />91 product <br />Sensor Functionality Test Result: r Pass lJ Fail <br />Interstitial Communication Test Result: V Pass f <br />Fail <br />5 <br />Component(s) Monitored by this Sensor: <br />91 vent <br />Sensor Functionality Test Result: WPass <br />r Fail <br />Interstitial Communication Test Result: V Pass f <br />Fail <br />6 <br />Component(s) Monitored by this Sensor: <br />DIESEL PRODUCT <br />Sensor Functionality Test Result: i�- Pass <br />r Fail <br />Interstitial Communication Test Result: Pass <br />Fail <br />7 <br />Component(s) Monitored by this Sensor: <br />dsl vent <br />Sensor Functionality Test Result: r Pass <br />r Fail <br />Interstitial Communication Test Result: V Pass f__ <br />Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass <br />r Fail <br />Interstitial Communication Test Result: r_ Pass I.. <br />Fail <br />Component(s) Monitored by this Sensor: <br />r <br />Sensor Functionality Test Result: t . Pass <br />r Fail <br />Interstitial Communication Test Result r Pass <br />Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass <br />r Fail <br />Interstitial Communication Test Result: r Pass r <br />Fail <br />How was interstitial communication verified? <br />Leak Introduced at Far End of Interstitial Space, r Gau <br />e r Visual Inspection r Other (Describe in Sec. J, below) <br />Vacuum was restored to operating levels in all interstitial spaces: <br />lV Yes r No (If no, describe in Sec. J, below) <br />i. comments tsuu enaracters max. use aamnonai sneers it <br />vac tested at sensor. s-2 and s-4 failed high liquid test. <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: 2310197 <br />