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RECEIVE® Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1,Enc. II I. Results of Vacuum/Pressure Monitoring Equipment Testing NOV 2 7 207 This page should be used to document testing and servicing of vacuum and press4'NNAW 'I�s)etj� CsNlhe clPlpy o l l this form must be included with the Monitoring System Certification Form, which must l��h�r3 1 i 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: 332175-001 System Type: ❑ Pressure; ® Vacuum Sensor ID S1 Component(s)Monitored by this Sensor: 87 Product Line Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result:® Pass; ❑ Fail Component(s)Monitored by this Sensor: 91 Product Line S2 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result:® Pass; ❑ Fail S3 Component(s)Monitored by this Sensor: Vent Lines Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result:® Pass; ❑ Fail Components)Monitored by this Sensor: 91 Vapor Vac-All vapor lines to dispensers S4 Sensor Functionality Test Result:® Pass; ❑ Fail Interstitial Communication Test Result:® Pass; ❑ Fail Component(s) Monitored by this Sensor: Diesel Product Lines S5 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 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(!f no, describe in Sec.J, below) J. Comments: Page I 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.