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Monitoring &W/ System Certification Form:Addendum for Vacuum/Pressure Interstitial Sensor e� 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; ® Vacuum J J� .f J J l J J J Sensor ID �%l/ 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 S3 Component(s)Monitored by this Sensor: Vent Line 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:M Pass; ❑ Fail Interstitial Communication Test Result: M Pass; ❑ Fail Component(s)Monitored by this Sensor: Diesel Product Line SS 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, beloll) Vacuum was restored to operating levels in all interstitial spaces: M Yes ❑No(/f no, describe in Sec. J below) J. Comments: RECEIVED Page 6 of 6 NM/ 2 0 ZU`r ENVIRONMENTAL HEALTH DEPARTMENT ' 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.