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ED Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors 2017 I. Results of Vacuum/Pressure Monitoring Equipment Testing ENVIR0N&4ENIAL HEgLTM This page should be used to document testing and servicing of vacuum and pressure interstitial sensjr6T6j fFUW$ 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: VEEDER ROOT Model: TLS-350 System Type: ❑Pressure; ® Vacuum Sensor ID Component(s)Monitored by this Sensor: 87 line s1 Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail Component(s)Monitored by this Sensor: vapor line s2 Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail Component(s)Monitored by this Sensor: 91 line S3 Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail Component(s)Monitored by this Sensor: vents s4 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; ❑ Fai I 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? ® Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ❑ Visual Inspection; ® Other(Describe in Sec. J, below Was vacuum/pressure restored to operating levels in all interstitial spaces? ®Yes ❑No(If no, describe in Sec. J, below) J. Comments: 4-10-17 COULD NOT TEST COMUNICATION ON STP AND FILL SUMPS ELITE WILL REPAIR AND TEST 4-10-17 Waterloo Shell 4315 E Waterlood Rd Stockton Page 4 of 4 ' 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. UN-036A-1/1 www.unidoes.org Rev.01/26/06