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Dec 21 2007 11 : 49AM HP LASERJET FAX • P• 7 Monitoring System Certification Forr•ddendum for Vacuum/Pressure Interstitial Sensors LG 163-1, Enc. It 1. 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: Model: System Type: ❑Pressure; ❑ Vacuum Sensor 1113 Component(s)Monitored by this Sensor: Sensor Functionality Test Result:[(Pass; ❑ Fail Interstitial Com municatio est Result:❑Pass; ❑ Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:Q Pass; ❑ Fail Interstitial Cgil5munication Test Result: Q Pass; Q Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:Q Pass; ❑ Fail ling4itial Communication Test Result ❑Pass; ❑ Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:Q Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass; ❑ ail Interstitial Communication Test Result: ❑Pass; ❑ Fail Component(s)Monitored by this Sensor. Sensor Functionality Test Result: Q Pass- ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail Component(s)Monitored by this Se r: Sensor Functionality Test Result ass; E] Fail Interstitial Communication Test Result:[IPass; ❑ Fail Component(s)Monitored by th' Sensor: Sensor Functionality Test Resx#6❑Pass, ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail Component(s)Monitored this Sensor: Sensor Functionality Te esult❑ Pass; ❑ Fail Interstitial Communication Test Result:Q Pass; ❑ Fail Component(s)Monis ed by this Sensor: Sensor Functio=Lest Result:❑Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail How was interstitial comma cation verifled? ❑ Leak Introduced at Far Ond of Interstitial Space;` ❑ Gauge; ❑ Visual Inspection; ❑ other(Describe in Sec. J, below) Vacuum was restored t operating levels in all interstitial spaces: El ElNo (If no, describe in Sec. J, below) J. Comments: Page of 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.