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Monitoring System Certification Forn. dendum for Vacuum/Pressure Interstitial ;ors LC 163-1, Enc. 11 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: - - – 46 System Type: ❑ Pressure;® Vacuum Sensor IDll Component(s) Monitored by this Sensor: 87 PRODUCT Sensor Functionality Test Result: ® Pass; ❑ Bail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: 87 VENT Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: ---87 ANNULAR —S-3 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: 87 VAPOR SS=4 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail S-5 Component(s)Monitored by this Sensor: 91 PRODUCT Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail S-6 Component(s)Monitored by this Sensor: 91 VENT _.. Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail S-7 Component(s) Monitored by this Sensor: DIESEL PRODUCT Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: DIESEL VENT S=9 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: DIESEL -91 SPLIT ANNULAR 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) Vacuum was restored to operating levels in all interstitial spaces: ®Yes ❑No(If no, describe in Sec.J, below) J. Comments: Page of ' he 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.