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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1, Enc. II 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. Manufacturer: veeder-root Model: 464/463 System Type: r Pressure P Vacuum Sensor 11) Component(s) Monitored by this Sensor: 87 prod st 1 Sensor Functionality Test Result: h Pass r Fail Interstitial Communication Test Result: 1%0, Pass Fail s-2 Component(s) Monitored by this Sensor: 87 fill Sensor Functionality Test Result: P Pass r Fail Interstitial Communication Test Result: fyI Pass r Fail Component(s) Monitored by this Sensor: v.r. all udc Sensor Functionality Test Result: FVO Pass r Fail Interstitial Communication Test Result: %O Pass F Pail Component(s) Monitored by this Sensor: 91 prod st Sensor Functionality Test Result: FvO Pass r Fail Interstitial Communication Test Result: FO Pass F Fail s-5 Component(s) Monitored by this Sensor: 91 vent fill Sensor Functionality Test Result: P Pass r Fail Interstitial Communication Test Result: V! Pass Fail Component(s) Monitored by this Sensor: dsl prod -o Sensor Functionality Test Result: F Pass r Fail Interstitial Communication Test Result: 140 Pass I Fail Component(s) Monitored by this Sensor: dsl fill Sensor Functionality Test Result: I Pass r Fail Interstitial Communication Test Result: SO Pass I Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass r Fail Interstitial Communication Test Result: F Pa, I ail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass r Fail Interstitial Communication Test Result: F Pass I Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: r Pass r Fail Interstitial Communication Test Result: I Pass I Fail How was interstitial communication verified? '-. Leak Introduced at Far End of Interstitial Space' i Gauge r Visual Inspection r Other Describe in Sec. J, below Vacuum was restored to operating levels in all interstitial spaces: P Yes r No (If no, describe in Sec. J, below) max. use aaatttonat sneets it Page 4 of 4 1 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. WO: 2334431