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I. Results of Vacuum/Pressure Monitoring Equipment Testing This page should be used to document testing and servicing of vacuum and pressure interstitial sensors . A copy of this form must be included with the Monitoring System Certification Form, which must be provided to 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 . Model : TLS-350 System Type : ❑ Pressure ; ❑✓ Vacuum S ' 9 Component(s) Monitored by this Sensor : 87 Product Line S . 9 Sensor Functionality Test Result : E Pass ; ❑ Fail Interstitial Communication Test Result: Q Pass ; ❑ Fail S . 10 Component(s) Monitored by this Sensor: 87 Vent Line Sensor Functionality Test Result: 0 Pass ; ❑ Fail Interstitial Communication Test Result: E Pass; ❑ Fail S ' 11 Component(s) Monitored by this Sensor : Vapor Return Line Sensor Functionality Test Result : Q Pass; ❑ Fail Interstitial Communication Test Result: Q Pass; ❑ Fail S - 12 Component(s) Monitored by this Sensor: 91 Product Line Sensor Functionality Test Result: 0 Pass ; ❑ Fail Interstitial Communication Test Result: ❑ Pass ; ❑ Fail S - 13 Component(s) Monitored by this Sensor :91 Vent Line Sensor Functionality Test Result: [D Pass; ❑ Fail Interstitial Communication Test Result: El 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 Corns 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 ? Q 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? Q Yes ❑ No (If no, describe in Sec. J, below) J. Comments (500 characters max. use additional sheets if needed) : ' If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. Page 4 of