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11HY-23-2012 11:12 Ser, irz Station Sy t.ems Monitoring System Certification Forr ddendum for Vacuum/Pressure Interstitial T. Results of Vacuunl/Presstire Monitoring, Equipment Testing, 408 538 8888 P.10 •)rs LG 163-1, Enc. ll This page should be used to doeurnent testing and servicing of vacuum and pressure interstitial sensors. A copy of this form 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 Sys= Certification Forth to the local agency regulating UST systetns within 30 days of test date. Manufacturer: Model: 3 Svsteni Type. ❑ Pressure; [Vacuum Sensor 10 Component(s) Monitored by this Sensor; 4rR, j!j({- Sensor Functionalitv Test Result: ❑['ass; ❑ Fail Interstitial Communication Test Result: ass; ❑ Fail Component(s) Monitored by this Sensor: 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: ❑ Pail Component(s) Monitored by this Sensor: T Sensor Functionality Test Result: ❑ Pass; 0 Fail Interstitial Comtunication Test Result: ❑ Pass; ❑ bail Components) Monitored by this Sensor: Sensor Functionality'fest Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionalitv Test Result: ❑ Pass; ❑ Fail interstitial Communication Test Result: ❑ Pass: ❑ Fail Components) Monitored by this Sensor: Sensor Functionality West Result ❑ Pass; ❑ Fail Interstitial Communication Test Result; ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Parti; ❑ Fail Interstitial Communication Test Result: ❑ Pass; [I Fail Component(s) Monitored by this Sensor: Sensor Functionalitv Test Rcsult: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ bail How was interstitial communication verified? ❑ Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ❑ Visual Inspection; ❑ Other (Describe in Sec. J, below) Vacuum was restored to operating levels in all interstitial spaces: ❑ Yes ❑ No (If no, describe in Sec. J, helori) J. Comments: L V:74ec' S Lo �,-�.""L4 Page '_ of l if the sensor successfully detects a simulated vacuumipressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum/pressure .has been demonstrated to be communicating throughout the interstice.