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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors I. Results of Vacuum/Pressure Monitoring Equipment Testing LG 163-1, Enc. II 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: Va,-/ epa k Model: 3"U System Type: ❑ Pressure; acuum Sensor ID Component(s) Monitored by this Sectyar. �0 t 51 \ Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; ❑ Fail Mt,/ 4 Component(s) Monitored by this Se nso . 1/F Sensor Functionality Test Result: ass; ❑ Fail Interstitial Communication Test Result Pass; ❑ Fail Component(s) Monitored by this Sensor: ft Lo✓fir 3 Sensor Functionality Test Result: O'Fass; ❑ Fail Interstitial Communicatio Test Result: Pass; ❑ Fail Component(s) Monitored by this Se r: iO J Sensor Functionality Test Result: s; ❑ Fail Interstitial Communication Test Result: Pass; ❑ Fail GComponent(s) Monitored by this S r: '-t- im SJ Sensor Functionality Test Results; Sensor ❑ Fail Interstitial Communication Test Result: Pass; Q Fail Component(s) Monitored by this Sensor: S Sensor Functionality Test Result: QR(I'ss; ❑ nterstitial Coavnuni ation Test Result: Pass; ❑ Fail Fail I SSensor Component(s) Monitored by this Se r. Functionality Test Result: 7s; Q Fail Interstitial Communication Test Result: Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Q Pass; ❑ Fail Interstitial Communication Test Result: Q Pass; ❑ Fail Component(s) Monitored by this Sensor. Sensor Functionality Test Result: Q Pass; Q Fail Interstitial Communication Test Result: [] Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: 0 Pass; Q Fail Ho as interstitial communication verified? Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; El vistion; E] Other (Describe in Sec. J, below) Vacuum was restored to operating levels in all interstitial spaeest Yes ❑ No (If no, describe in Sec. J, below) J. Comments: -e�'� a_" insv /' /Or 1 t P O u.c CL--E- Page _ _ 1_ of If the sensor successfully detects a simulated vacuum/pressum leak introduced in the interstitial space at the furthest point from the sensor, vacuumlpressure has been demonstrated to be communicating thrpughout the interstice.