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w orx urger: Monitoring System Certification Form: Addendum for Vacuwn/Pressure Interstitial Sensors LG 163-1, Enc. I1 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 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: ` t& L,/ 1%(7D ` Model: V a System Type: [] Pressure FEl acuum Sensor ID 51 Con3ponent(s) Monitored by this SeWynn (p t Sensor Functionality Test Result: Pass; ❑ Fail Interstitial Communication Test Result: Pass; ❑ Fail Components) Monitored by this Senso Sensor Functionality Test Result; ass; ❑ Fail Interstitial Communication Test Result: Pass; ❑ Fail Components) Monitored by this S,ensor. /lZ C o ✓P.r Sensor Functionality Test Result: Imo'; ❑ Fail Interstitial Crnmunicatio Test Result: Pass; ❑ Fail F�A Component(s) Monitored by this Se r. / DSensor Functionality Test Result: �; ❑ Faii Interstitial Communication Test Result: Pass: ❑ Fail S/ L� Component(s) Monitored by this Serywr: Sensor Functionality Test Result: M. eC11: ❑ Fail ti's Interstitial Communication Test Result: Pass; ❑ Fail S Component(s) Monitored by this Se r. Sensor Functionality Test Resin,. 71, ❑Fail Interstitial anon Test Result: ET s; El Fail Compoaent(s) Monitored by thirels,7 Sensor Functionality Test Restrlt' ❑ Fail ,C`ommuni Interstitial Communication Test Result: Pass; ❑ Fail Component(s) Monitored by this Sensor. Sensor Functionality Test Result: El Pass; ❑ Fail Interstitial Communication Test Result: Pass; Fail Components) Monitored by this Saw - Sensor Functionality Test Result: [2 Pass, ❑ Fail Interstitial Communication Test Result: ❑ Pass; Fall Component(s) Monitored by this Sensors Sensor Functionality Test Result: ❑ Pass; j] Fat] Int ustitial Communication Test Result: ❑Pass; [] Fail Ro interstitial mmmuniatlon verified Leak Introduced at Far End of Interstitial S ace; ❑Gauge; ❑Vis on; ❑Other (Describe in Sec. I, below) ,.,...ting levels in all intensdtial spaces: Xes ❑ No (!f no, describe in Sec. J, below) J. Comments: s-{ aw --9✓I t -.e Se SSD i� i rl c� c ct�-e Page of t If the sensor successfully detects a simulated vacuumlpressura leak introdu�ner n sensor, in the al space at the furthest point from else movacuumtpresswe has been denstrated to be communicating thrp ghout the in Tanknology Inc. 11000N. MoPac Expressway, Suite 500, Austin, Texas 78759