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11 HEUEIVED <br /> Monitoring System Certification Form endum for Vacuum/Pressure Interstitial rs <br /> 1 <br /> I. Results of Vacuum/Pressure Monitoring Equipment Testing <br /> This page should be used to document testing and servicing of vacuum and pressure interstit <br /> this form must be included with the Monitoring System Certification Form, which must be provided to thetan <br /> rr <br /> system owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form to the <br /> local agency regulating UST systems within 30 days of test date. <br /> Manufacturer:VEEDER ROOT Model: TLS-350 System Type: ❑Pressure; ®Vacuum <br /> NO ffiffiffiffiffiffiffiffia <br /> Sensor ID MENEENNEEMEM <br /> S -1 Component(s)Monitored by this Sensor: FUEL OIL RETURN LINE <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> S-2 Component(s)Monitored by this Sensor: FUEL OIL SUPPLY LINE <br /> Sensor Functionality Test Result: ❑Pass; ® Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> S-3 Component(s)Monitored by this Sensor: VENT LINE <br /> Sensor Functionality Test Result: ®Pass; (_f Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: REMOTE FILL LINE <br /> S-4 <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> How was interstitial communication verified? <br /> ❑ Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ® Visual Inspection; ❑ Other(Describe in Sec.J, 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: Lodi Memorial 10-8-15 <br /> S-2 1 1nl 11n Fl CHAT NOT OPERATING NO 11Ql I1D DETECTION El ITE IV to repair& Retest <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 />