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Monitoring System Certification For* or ddendum for Vacuum/Pressure Interstiti*nsors RECEIVED 0 a I. Results of Vacuum/Pressure Monitoring Equipment Testing FES 0 5 204 This page should be used to document testing and servicing of vacuum and pressure interstit' AL this form must be included with the Monitoring System Certification Form, which must be T system owner/operator. The owner/operator must submit a copy of the Monitoring System Certi 1catlonorm tot e local agency regulating UST systems within 30 days of test date. IManufacturer: VEEDER ROOT a Model: TLS 350 1 System Type: ❑ Pressure; ® Vacuum N Sensor ID J. Comments: Sensor to be repaired and retested by Central Petroleum Country Club Valero - 2575 Country Club - Stockton - 1-14-14 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.unidocs.org Rev. 01/26/06 Component(s) Monitored by this Sensor: 87 PRODUCT S1 Sensor Functionality Test Result: ❑ Pass; ® Fail Interstitial Communication Test Result: ® Pass; ❑ 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: ® 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: DIESEL PRODUCT 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 Components) 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: Sensor to be repaired and retested by Central Petroleum Country Club Valero - 2575 Country Club - Stockton - 1-14-14 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.unidocs.org Rev. 01/26/06