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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors <br />LG 163-1, Enc. II <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: 463/464 <br />System Type: r Pressure P Vacuum <br />Sensor ID <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: <br />Pass Fail <br />Component(s) Monitored by this Sensor: <br />r Fail <br />Sensor Functionality Test Result: Pass r <br />Interstitial Communication Test Result: <br />Pass Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: <br />Pass Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: <br />Pass Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: <br />Pass Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: <br />Pass Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: <br />Pass Fail <br />Components) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: <br />Pass Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: <br />Pass Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: r Pass r Fail <br />Interstitial Communication Test Result: <br />Pass Fail <br />How was interstitial communication verified? <br />"O Leak Introduced at Far End of Interstitial Space' r Gauge r Visual Inspection <br />r Other Describe in Sec. J, below <br />Vacuum was restored to operating levels in all interstitial spaces: <br />F Yes r No (Ifno, describe in Sec. J, below) <br />JUST TESTED COMMUNICATION ON ALL UDC'S AND ALL SUMPS ON SITE.... TESTED WITH INSPECTOR AND THEY ALL PASSED.... <br />Page 3 of 2 <br />1 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 />W0: 2334971 <br />