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8-22-07;10:23AM;5ACRAME11O EMC <br />• <br />;816 925 2816 x A— <br />Sacramento Equipment Maintenance Company, Inc <br />Work Order # 126686 <br />Site Address: <br />2190 <br />South <br />Date of Testing/Servicing: <br />08-21-07 <br />❑Vacuum <br />4943 State Route 99 <br />Pass <br />Fail <br />Stockton, Ca. 95602 <br />Pass <br />Fail <br />209-939-0679 <br />Results of Vacuum/Pressure Monitoring Equipment Testing <br />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 <br />the Monitoring System Certification Form, which must be provided to the tank system owner/operator. The owner/operator must submit a copy of <br />the Monitoring System Certification Form to the local agency regulating UST systems within 30 days of test date. <br />Manufacturer: <br />Model: <br />I System Type: <br />❑Pressure <br />❑Vacuum <br />Sensor ID <br />Pass <br />Fail <br />Pass <br />Fail <br />Component(s) monitor by this Sensor <br />Sensor Functionality Test Resuhs: <br />Inimstitial Communication Test Result: <br />Component(s) monitor by this Sensor <br />Sensor Functionality Test Results: <br />Interstitial Communication Test Result: <br />Component(s) monitor by this Sensor <br />Sensor Functionality Test Results: <br />Immtiliai Communication Test Result: <br />Compone rt(s) monitor by this Sensor <br />Sensor Functionality Test Results: <br />Interstitial Communication Test Result: <br />7-1 <br />Component(s) monitor by this Sensor <br />Sensor Functionality Test Results: <br />Interstitial Communication Test Result: <br />Component(s) monitor by this Sensor <br />Sensor Functionality Test Results: <br />Interstitial Communication Test Result: <br />Component(s) monitor by this Sensor <br />Sensor Functionality Test Results: <br />1--t—h ial Communication Test Result: <br />Component(s) monitor by this Sensor <br />Sensor Functionality Test Results: <br />Interstitial Communication Test Result: <br />Component(s) monitor by this Sensor <br />Sensor FunctionalityTest Results: <br />hft-litial Communication Test Result: <br />Component(s) monitor by this Sensor <br />Sensor Functionality Test Results: <br />Interstitial Communication Test Result <br />How was interstitial communication verified? <br />Leak Introduced at Far End of Interstitial Space; (1) <br />Gauge; <br />Visual Inspection <br />Other (Describe in section. <br />J, below) <br />Vacuum was restored to operating levels in all interstitial spaces: <br />Yes <br />No (if no, describe in <br />section J, below <br />J. Comments: <br />(1) If the sensor successfiilly detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the <br />sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. <br />03101 county/00OOf/state/3•monitoringcert.wpd Page 5 of 6 <br />