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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors I. Results of Vacuum/Pressure Monitoring Equipment Testing LG 1634, Enc. II 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. Manufacturer: Veeder Root Model: 330020463 System Type: ❑ Pressure; Vacuum ID OF z /i FN � i; �;i/%�;//�j%/ % � %///% i/ . i i/ i,% /" NE/1111/1' ��//;%�i"��%/i%%,j%,�,��/�/�; ////",�i��/" �� /,�/;�/�i� / �,/;�;/;, / //,� /�/%/, /i"i /�' , Sensor /, , i// i //%i �i, ,/i ii ii �i, i i/�i i /,�i//; „ '22& Component(s) Monitored by this Sensor: Regular Vac Product S-2 Sensor Functionality Test Result: ® Pass; ElFail Interstitial Communication Test Result: ®Pass; ❑Fail Component(s) Monitored by this Sensor: Regular STP Vac Vapor S-3 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; Fail Component(s) Monitored by this Sensor: Regular STP Vac Vent S-4 Sensor Functionality Test Result: X❑ Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: Premium Vac Product S-7 Sensor Functionality Test Result: ❑X Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: premium Vac Vent S-8 Sensor Functionality Test Result: Q Pass; ❑Fail Interstitial Communication Test Result: ®Pass; Fail ME I RM, NOR Component(s) Monitored by this Sensor: Diesel Vac Product 5-11 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: Diesel Vac Vent S-12 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: El Pass; El 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 Other (Describe in Sec. J, Vacuum was restored to operating levels in all interstitial spaces: ® Yes ❑ No (If no, describe in C. J, below) 1. Comments: Com feted 8-28-2018 _ � m ENVIRONMENTAL HEALTH PERMITISERVlCES Page 1 of 1 1 If the sensor successfully detects a simulated sensor, vacuum/pressure vacuum/pressure leak introduced in the interstitial space at the furthest point from the has been demonstrated to be communicating throughout the interstice.