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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: V Model: &m TLS C v System Type: ❑ Pressure; Vacuum Sensor ID - Component(s) Monitored by this Sensor: l Sd Sensor Functionality Test Result: ®-Pass; ❑ Fail Interstitial Communication Test Result: f -Pass; ❑ Fail Component(s) Monitored by this Sensor: g 14 cI L I-)f-14J� S Sensor Functionality Test Result: rass; l� ❑ Fail Interstitial Communication Test Result: amass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Q Pass; Q 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; Q 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- ensorSensor SensorFunctionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: E Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Q Pass; Q Fail Interstitial Communication Test Result: Q Pass; ❑ Fail Component(s) Monitored by this Sensor. Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: Q Pass; Q Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Q Pass; r] Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail How was interstitial communication verified? [Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ❑ Visual Inspection; ❑ Other (Describe in Sec. J, below) Vacuum was restored to operating levels in all interstitial spaces: O -Y -es ❑ No (If no, describe in Sec. J, below) J. Comments: t4 --� ps P Z l7 �' C �✓ Page —�_ of ' If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuumi/pressure has been demonstrated to be communicating thrpughout the interstice.