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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sen rs LG 163-1,Enc.II <br /> or g y <br /> I. Results of Vacuum/Pressure Monitoring Equipment Testing <br /> This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of <br /> this form must be included with the Monitoring System Certification Form, which must be provided to the tank <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: 330020-463 System Type: ❑Pressure; ® Vacuum <br /> iiri;iiii <br /> Sensor ID /; / /U <br /> Component(s)Monitored by this Sensor: Regular Vac Product <br /> S-2 <br /> Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; Fail <br /> Component(s)Monitored by this Sensor: Regular STP Vac Vapor <br /> S-3 <br /> Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; E] Fail <br /> Component(s)Monitored by this Sensor: Regular STP Vac Vent <br /> S-4 Sensor Functionality Test Result: X❑Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: Premium Vac Product <br /> S-7 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: premium Vac Vent <br /> S-8 <br /> Sensor Functionality Test Result: ®Pass; El Fail Interstitial Communication Test Result: KI Pass; El Fail <br /> Component(s) Monitored by this Sensor: Diesel Vac Product <br /> S-11 Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail <br /> Component(s) Monitored by this Sensor: Diesel Vac Vent <br /> S-12 <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 /> Q Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ❑ Visual Inspection; ❑ Other(Describe in Sec. J, below) <br /> Vacuum was restored to operating levels in all interstitial spaces: ® Yes ❑ No (If no, describe in Sec.J, below) <br /> J. Comments: Completed 8-28-2018 <br /> /�- rte- �/� Page 1 of 1 <br /> /1^..GtL- G/Phi <br /> i 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 />