INSTALL_2014 B100 - Laserfiche WebLink

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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. yy Model: Veeder Root TLS 350 System Type: El Pressure;0Vacuum a [+ N @ IN Component(s)Monitored by this Sensor: S-1 Bio Product vac Sensor Functionality Test Result: ❑x Pass; ❑ Fail Interstitial Communication Test Result: ❑>< Pass; ❑ Fail Component(s)Monitored by this Sensor: S-2 Bio Product Vac Dispenser RV& 19-20 Sensor Functionality Test Result: ❑x Pass; ❑ Fail Interstitial Communication Test Result: 1]Pass; ❑ Fail Component(s)Monitored by this Sensor: S-3 Bio Product Vac Dispenser 21-30 Sensor Functionality Test Result: ❑+` Pass; ❑ Fail Interstitial Communication Test Result: z❑Pass; ❑ Fail Component(s)Monitored by this Sensor: L-7 Vent secondary Pipe hydrostatic Sensor Functionality Test Result: 0 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 How was interstitial communication verified? ❑K Leak Introduced at Far End of Interstitial Space; ❑ Gauge; ED Visual Inspection; ❑ Other(Describe in Sec.J, below Was vacuum/pressure restored to operating levels in all interstitial spaces? z❑Yes ❑No(If no, describe in Sec.J, below) J. Comments(500 characters max.use additional sheets if needed): '. RECEIVED APR 16 2014 ENVIRONMENTAL HEALTH DEPARTMENT 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. '.. Page 4 of