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1 0 * RECEIVED <br />Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors <br />JAN 2 1215 <br />I. Results of Vacuum/Pressure Monitoring Equipment Testing <br />This rage should be used to document testing and servicing of vacuum and pressure interstitial il 'r <br />form must be included with the Monitoring System Certification Form, which must be provided to the tank system <br />owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form to the local <br />agency regulating UST systems within 30 days of test date. <br />Manufacturer: VEEDER ROOT Model: TLS 350 System Type: ❑ Pressure; ® Vacuum <br />3 <br />Sensor ID <br />Component(s) Monitored by this Sensor: 87 PRODUCT <br />S1 <br />Sensor Functionality Test Result: ❑Pass; ®Fail Interstitial Communication Test Result: ®Pass; <br />❑Fail <br />Component(s) Monitored by this Sensor: 87 TANK ANNULAR <br />S2 <br />Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; <br />❑ Fail <br />Component(s) Monitored by this Sensor: 91 PRODUCT <br />S3 <br />Sensor Functionality Test Result: ®Pass; E] Fail Interstitial Communication Test Result: ®Pass; <br />❑Fail <br />Component(s) Monitored by this Sensor: 91 TANK ANNULAR <br />S4 <br />Sensor Functionality Test Result: ®Pass; El Fail Interstitial Communication Test Result: ®Pass; <br />El Fail <br />Component(s) Monitored by this Sensor: DIESEL PRODUCT <br />S5 <br />Sensor Functionality Test Result: ®Pass; El Fail Interstitial Communication Test Result: ®Pass; <br />❑Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; <br />❑ Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; <br />❑ Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; <br />❑ Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; <br />❑ Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; <br />❑ Fail <br />How was interstitial communication verified? <br />❑ Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ® Visual Inspection; ❑ Other (Describe in Sec. <br />J, <br />below <br />Was vacuum/pressure restored to operating levels in all interstitial spaces? ® Yes ❑ No (If no, describe in Sec. J, below) <br />J. Comments: Country Club Valero <br />1 -14 - <br />Page 4 of 4 <br />If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the <br />sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. <br />UN -036A -1/1 www.unidocs.org Rev. 01/26/06 <br />