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Monitoring System Certification Form:Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1,Enc. II I. 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: Veeder Root Model: 330020-463 System Type: ❑ Pressure; E Vacuum ,/, ,�% �/ii/ //• i�/ i;i•/• , i ;i/i/ /,�• % ii/ %' ,// i/•i i•,//iii ; i ;•,•i••,i; • Sensor ID %�� !//,�i/� ��//�/, //i/%��j%///i/ � j, i i•///i is,�/ / j� S-1 Component(s)Monitored by this Sensor: 87 PRODUCT VAC Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: [ Pass; ❑ Fail S-2 Component(s)Monitored by this Sensor: 87 VENT VAC Sensor Functionality Test Result: ER Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail S-3 Component(s)Monitored by this Sensor: 87 ANNULAR VAC Sensor Functionality Test Result: [2 Pass; ❑ Fail Interstitial Communication Test Result: Pass; ❑ Fail S-4 Component(s)Monitored by this Sensor: 87 VAPOR VAC Sensor Functionality Test Result:B Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail S-5 Component(s)Monitored by this Sensor: 91 PRODUCT VAC Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result:91 Pass; ❑ Fail Component(s)Monitored by this Sensor: 91 VENT VAC S-6 Sensor FunctionalityTest Result: Pass; [� El Fail Interstitial Connnunication Test Result: Pass; ❑ Fail S-7 Component(s)Monitored by this Sensor: DSL PRODUCT VAC Sensor Functionality Test Result: Pass; ❑ Fail Interstitial Communication Test Result: Pass; ❑ Fail S-9 Component(s)Monitored by this Sensor: DSL VENT VAC Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: [2 Pass; ❑ Fail S-10 Component(s)Monitored by this Sensor: DSL-91 ANNULAR VAC 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? 0 Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ❑ Visual Inspection; ❑ Other(Describe in Sec.J, below) Vacuum was restored to operating levels in all interstitial spaces: ®Yes ❑No(If no, describe in Sec.J, below) J. Comments: All tested and passed. Page 1 of_1 ' 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.