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Monitoring System Certification Forin. Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1, Enc. II <br /> Y. Results of Vacuum/Pressure Monitoring Equipment Testing <br /> This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of <br /> this form must be included with the Monitoring System Certification Form, which must be provided to the tank <br /> system owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form to the <br /> local agency regulating UST systems within 30 days of test date. <br /> Manufacturer: Veeder Root Model: 330020-463 System Type: ❑ Pressure; ❑x Vacuum <br /> /;,// / !, /i/� i,,i; .i <br /> 'w' ,;; ,i,!„ // / i% / s„ <br /> /�ii „/ii/Sensor ID /i� i;�/�'V& 1 / �iicz;i /% ; i ///; <br /> S-1 Component(s)Monitored by this Sensor: 87 PRODUCT VAC <br /> Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: [R Pass; ❑ Fail <br /> S-2 Component(s) Monitored by this Sensor: 87 VENT VAC <br /> Sensor Functionality Test Result: ER Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> S-3 Component(s) Monitored by this Sensor: 87 ANNULAR VAC <br /> Sensor Functionality Test Result: [2 Pass; ❑ Fail Interstitial Communication Test Result: Pass; ❑ Fail <br /> S-4 Component(s) Monitored by this Sensor: 87 VAPOR VAC <br /> Sensor Functionality Test Result: [3 Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> S-5 Component(s)Monitored by this Sensor: 91 PRODUCT VAC <br /> Sensor Functionality Test Result: Z Pass; ❑ Fail Interstitial Communication Test Result:g] Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: 91 VENT VAC <br /> S-6 Sensor Functionality Test Result: 15d Pass; ❑ Fail Interstitial Communication Test Result: [5j Pass; ❑ Fail <br /> S-7 Component(s) Monitored by this Sensor: DSL PRODUCT VAC <br /> Sensor Functionality Test Result: 5a Pass; ❑ Fail Interstitial Communication Test Result: Pass; ❑ Fail <br /> S-9 Component(s)Monitored by this Sensor: DSL VENT VAC <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: E2 Pass; ❑ Fail <br /> S-10 Component(s) Monitored by this Sensor: DSL-91 ANNULAR VAC <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 /> 0 Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ❑ Visual Inspection; ❑ Other(Describe in Sec.J, below) <br /> Vacuum was restored to operating levels in all interstitial spaces: ® yes ❑No (If no, describe in Sec.J, below) <br /> J. Comments: All tested and passed. <br /> Page 1 of_I <br /> ' If the sensor successfully detects a simulated vacuum/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 />