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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: vph <br />System Type: ❑ Pressure R Vacuum <br />Sensor ID <br />1 Component(s) lionitored by this Sensor: <br />87 product <br />Sensor Functionality Test Result: P Pass r I ai I <br />Interstitial Communication Test Result: Fel Pass <br />.. Fail <br />Component(s) Monitored by this Sensor: <br />87 vent <br />s-2 <br />1� <br />Sensor Functionality Test Result: r. Pass 17 Fail <br />Interstitial Communication Test Result: hel Pass <br />-_._ Fail <br />3 <br />Component(s) Monitored by this Sensor: <br />vapor recove <br />Sensor Functionality Test Result: P Pass ❑ Fail <br />Interstitial Communication Test Result:NJ Pass <br />Fail <br />s-4 <br />Component(s) Monitored by this Sensor: <br />91 product <br />1--I <br />Sensor Functionality Test Result: LJ Pass n Fail <br />Interstitial Communication Test Result: 110i Pass <br />.._.. Fail <br />s-5 <br />Component(s) Monitored by this Sensor: <br />91 vent <br />1:,, 1� <br />Sensor Functionality Test Result: P_ 1 Pass LJ Fail <br />Interstitial Communication Test Result: F Pass <br />17 Fail <br />6 <br />Component(s) Monitored by this Sensor: <br />DIESEL PRODUCT <br />Sensor Functionality Test Result: R Pass ❑ Fail <br />Interstitial Communication Test Result: bel Pass <br />El Fail <br />7 <br />Component(s) Monitored by this Sensor: <br />dsl vent <br />Sensor Functionality Test Result: n Pass ❑ Fail <br />Interstitial Communication Test Result: Pass <br />_! Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass ❑ Fail <br />Interstitial Communication Test Result: _._l Pass <br />Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass ❑ Fail <br />Interstitial Communication Test Result: Pass <br />Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: L_I Pass ❑ Fail <br />Interstitial Communication Test Result: Pass <br />Fail <br />How was interstitial communication verified? <br />Leak Introduced at Far End of Interstitial Space' r. � Gauge ❑ Visual Inspection ❑ Other Describe in Sec. J, below <br />Vacuum was restored to operating levels in all interstitial spaces: <br />F(Yes r! No (If no, describe in Sec. J, below) <br />r. comments ]-nuu enaracters max. use aoumonai sn <br />vac tested at sensor. s-2 and s-4 failed high liquid test. <br />Page 4 of 4 <br />I 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 />WO: 2310197 <br />