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0 0 <br /> Fast Lane Lathrop (Truck Side), 116 E Roth Rd, Lathrop, <br /> CA 95330 BVEC <br /> NOV 0 2 2016 <br /> Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors <br /> ENVIRONMENTAL HEALTH <br /> I. Results of Vacuum/Pressure Monitoring Equipment Testing DEPARTI/IENT <br /> This page should be used to document testing and servicing of vacuum and pressure intcrstitial sensors.A copy of this form must be included <br /> with the Monitoring System Certification Form,which must be provided to the tank system owner/operator.The owner/operator must submit a <br /> copy of the Monitoring System Certification Form to the local agency regulating UST systems within 30 days of test date. <br /> Manufacturer: Veeder Root Model: System Type: ❑ Pressure; 0 Vacuum <br /> Sensor <br /> Component(s)Monitored by this Sensor: Diesel South Piping <br /> S1 <br /> Sensor Functionality Test Result: ©Pass; El Fail Interstitia]Communication Test Result: ❑ Pass; El Fail <br /> Component(s)Monitored by this Sensor: Diesel South Vent Line <br /> S2 <br /> Sensor Functionality Test Result: EZ Pass; ❑ Fail Interstitial Communication Test Result: El Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: Diesel North Piping <br /> S3 <br /> Sensor Functionality Test Result: 0 Pass; E] Fail Intersti#ial Communication Test Result: ❑ Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: Diesel North Vent Line <br /> 54 Interstitial Communication Test Result: Pass Fail <br /> Sensor Functionality Test Result:i�Foss; El Fail ❑ � ❑ <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s) Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result:❑ Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> �71Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br /> How was interstitial communication verified? <br /> ❑ Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ❑ Visual Inspection; <br /> ❑ Other(Describe in Sec. J,beloiv <br /> \\'as vacuum/pressure restored to operating levels in all interstitial spaces? <br /> ❑ Yes ❑ No(Lf no, describe in Sec. j below) <br /> J. Comments: Still need to test communications. <br /> Page 4 of S <br /> ' If the sensor successfully detects a simulated vacuurn/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 /> www.unidocs.org <br />