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Monitoring System Certification Foroddendurn for Vacuum/Pressure Interstiti*sors 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 Component(s)Monitored by this Sensor: 87 PRODUCT _ S1 Sensor Functionality Test Result: ® Pass; El Fail Interstitial Communication Test Result: ® Pass; El Fail Component(s)Monitored by this Sensor: 87 TANK ANNULAR S2 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: 91 PRODUCT S3 Sensor Functionality Test Result: X Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ® Fail Component(s)Monitored by this Sensor: 91 TANK ANNULAR S4 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: DSL PRODUCT S5 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fai I 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) was vacuum/pressure restored to operating levels in all interstitial spaces? ® Yes ❑No (If no, describe in Sec. J, below) J. Comments: ALL VAC i3 SENSORS PASSED Page 4 of 4 ' If the sensor successfully detects a simulated vacuum/pressureleak 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