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Monitoring System Certification Form ldendum for Vacuum/Pressure Interstitial ;ors 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 Sensor ID S - 1 Component(s) Monitored by this Sensor: 87 PRODUCT LINE Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail S -2 Component(s)Monitored by this Sensor: VAPOR RETURN LINE Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: 91 PRODUCT LINE S -3 Sensor Functionality Test Result: 0 Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail S -4 Component(s)Monitored by this Sensor: 87191 VENT LINES Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail S -5 Component(s)Monitored by this Sensor: DIESEL PRODUCT LINE Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail S -6 Component(s)Monitored by this Sensor: DIESEL VENT LINE 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) Was vacuum/pressure restored to operating levels in all interstitial spaces? ® Yes ❑No (If no, describe in Sec.J, below) J. Comments: Angle Petroleum - 99 Shell - 8-22-17 RFGF1N.fFEL)- IVDv ® F 2017 ENVIRONMENTAL HEALTH nPPARTMENT age 4 of 4 ' 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. UN-036A-1/1 www.unidoes.org Rev.01/26/06