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MAY -23-2012 11:18 Service Station Systems 408 938 8888 P.05 Monitoring System Certification For Adendum for Vacuum/Pressure Interstitial, .yrs LG 163-1, line. 11 I. Results of Vacuum/Pressure Monitoring Equipment Testing This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of this f )rm must he 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 Foran to the local agency regulating; UST systems within 30 days of test date. Manufacturer; t� rL :Model: � � � J'Sy Ste m Type: ❑Pre sure; ❑vacuum Sensor 1D Fm Component(s) Monitored by this Sensor: Yp, Sensor Functionality Test Result; ©lass; ❑ Fail Interstitial Conununication Test Result: 2 sass; ❑ fail Components) Monitored by this Sensor: Sensor Functionality Test Result Wdsa; ❑ bail Interstitial Communication Test Result: ( _71ss; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Tcst Result: ❑ Pass; ❑ Fail ?. Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail _ Interstitial Communication Test Result: ❑ Pass; ❑ Fail Components) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: f Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: �Conununication Sensor functionality Test Result ❑ Pass; ❑ Fail Interstitial 'fest Result: ❑ Pass: ❑ Fail Componcnt(s) Monitored by this Sensor: I Sensor Functionality Test Rcsult: ❑ 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 was interstitial communication verified? (HH Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ❑ Visual Inspection; ❑ Dthcr (Describe in Sec. .7, helow) Vacuum was restored to operating levels in all interstitial spaces: [d'i'es ❑ No (If no, davc-rite in See, J, below] I Comments: r Page i of _„L If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at cite furthest point from the sen4or, vaeuuni/pressure has been demonstrated w be communicating throughout the interstice.