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RECEIVED Monitoring System Certification Form:Addendum for Vacuum/Pressure Interstitial Sensors NOV 0 5 2015 I. Results of Vacuum/Pressure Monitoring Equipment Testing This page should be used to document testing and servicing of vacuum and pressure interstitialI OFJCI NQU , form must be included with the Monitoring System Certification Form, which must be providedo 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 LEI S-1 Component(s)Monitored by this Sensor: FUEL OIL RETURN LINE Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result:®Pass; ❑ Fail S -2 Component(s)Monitored by this Sensor: FUEL OIL SUPPLY LINE Sensor Functionality Test Result: ❑Pass; ® Fail Interstitial Communication Test Result: ®Pass; ❑ Fail S -3 Component(s)Monitored by this Sensor: VENT LINE Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail S -4 Component(s)Monitored by this Sensor: REMOTE FILL 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 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: Lodi Memorial 10-8-15 S-2 LIQUID FLOAT NOT OPERATING NO LIQUID DETECTION. ELITE IV to repair& Retest. 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