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Vj Monitoring System Certification Form Idendum for Vacuum/Pressure Interstitial sors �U ,.---CHEM COMPLIANCE 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: TLS 350 System Type: ❑ Pressure; M Vacuum ............ 'E K� .�f .../..f i:a. ✓.� W'3l:'.3:.,...::.'.ysi..E�..v.,...;,.._:::. f �..:. "vim..: Component(s)Monitored by this Sensor: 87 Product Line S1 Sensor Functionality Test Result: M Pass; ❑ Fail Interstitial Communication Test Result: M Pass; ❑ Fail Component(s)Monitored by this Sensor: 91 Product Line S2 Sensor Functionality Test Result: M Pass; ❑ Fail Interstitial Communication Test Result: M Pass; ❑ Fail Component(s)Monitored by this Sensor: Vent Line S3 Sensor Functionality Test Result: M Pass; ❑ Fail Interstitial Communication Test Result: M Pass; ❑ Fail Component(s)Monitored by this Sensor: 91 Vapor Line S4 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: M Pass; ❑ Fail Component(s)Monitored by this Sensor: Diesel Product Line S5 Sensor Functionality Test Result: M Pass; ❑ Fail Interstitial Communication Test Result: M 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; ❑ 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? M 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: M Yes ❑No (If no, describe in Sec.J, below) J. Comments: STP and FILL Sumps communication was tested on 11-22-2016 2017 Page 6 of 6 ENVIFIONMEW,,1- HEALTH r-FRI-�/I-NT ' 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.