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SEP 3 0 2016 <br /> Facility Name: Costco#658 Tracy (Page 4) <br /> I. Results of Vacuum/Pressure Monitoring Equipment Testing ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> Manufacturer: Veeder-Root Model : 331117 <br /> System Type: EJ Pressure ®Vacuum <br /> Sensor <br /> ID <br /> s9 Component(s) Monitored by this Sensor: Additive Product Line <br /> sensor Functionality Test Results: ® Pass; ❑ Fail Interstitial Communication Test Result: <br /> s1 o Component(s) Monitored by this sensor: Additive Vent Line ® Pass: 171 Fail <br /> Sensor Functionality Test Results: ® Pass; ❑ Fail Interstitial Communication Test Result: <br /> Sensor Functionality Test Results: ® Pass; ® Pass: El Fail <br /> How w 11 as interstitial communication verified? ❑ Fail interstitial Communication Test Result: ® Pass: ❑ Fail <br /> ® Leak Introduced at Far End of Interstitial Space; ❑ Gauge; ❑ Visual Inspection; Other (Describe in 1 below) <br /> Vacuum was restored to operating levels in ali interstitial spaces: ® Yes <br /> ❑ l�lo (If no, describe in l below) <br /> J. Comments: <br />