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'r- i"lz Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1, Enc. II I. Results of Vacuum/Pressure Monitoring Equipment Testing 4 qoj' 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: r„ Model: L� System Type: ❑ Pressure; ❑ Vacuum Sensor ID Component(s) Monitored by this Sensor:- 5—C� Sensor Functionality Test Result: [amass; ❑ Fail Interstitial Communication Test Result: [')sass; ❑ Fail Component(s) Monitored by this Sensor: LO Sensor Functionality Test Result: [ ass; ❑ Fail Interstitial Communication Test Result: H-Fass; ❑ 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: ❑ 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: ❑ 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 Ho was interstitial communication verified? I Leak at Far End of Interstitial Space;' ❑ Gauge; [k ❑ Visual Inspection; ❑ Other (Describe in Sec. J, below) Vacuum was restored to operating levels in all interstitial spaces: ['Yes ❑ No (If no, describe in See. J, below) J. Comments: o,� f4tp' .� Page 1 of If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice.