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Work Order: 2280901 <br />Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial SensorsLG 163-1, Enc. <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 <br />sensors. A copy of this form must be included with the Monitoring System Certification Form, <br />which must be provided to the tank system owner/operator. The owner/operator must submit a copy <br />of the Monitoring System Certification Form to the local agency regulating UST systems within 30 <br />days of test date. <br />Manufacturer. V Model: bd <br />System Type: ❑ Pressure; Q Vacuum <br />Sensor ID <br />Component(s) Monitored by this Sensor: <br />S- I�61 <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 kPass• ❑ Fail <br />Interstitial Communication Test Result: ass <br />Fail <br />48V <br />Component(s) Monitored by this Sensor: <br />S-3 <br />Sensor Functionality Test Result: ass; ❑ Fail <br />Interstitial Communication Test Result Pass <br />Fail <br />ai <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: 19 Pass; ❑ Fail <br />Interstitial Communication Test Result: W Pass <br />Fail <br />AA <br />Component(s) Monitored by this Sensor: <br />S-5 vtrlk <br />Sensor Functionality Test Result:0 Pass; ❑ Fail <br />Interstitial Communication Test Result W Pass <br />Fail <br />%U <br />Component(s) Monitored by this Sensor: <br />SAo <br />Sensor Functionality Test Result: 159"Pass; ❑ Fail <br />Interstitial Communication Test Result: W Pass <br />Fail <br />P5L <br />Component(s) Monitored by this Sensor: <br />X44 <br />Sensor Functionality Test Result: aPass• ❑ 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: Pass <br />Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail <br />Interstitial Communication Test Result: B4 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 />How was interstitial communication verified? <br />❑ Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; (g Visual Inspection; ❑ Other Describe in Sec. J, below <br />Vacuum was restored to operating levels in all interstitial spaces: W Yes ❑ No (If no, describe in Sea J, below) <br />' If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest <br />point from the sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. <br />Tanknology Inc. 11000 N. MoPac Expressway, Suite 500, Austin, Texas 78759 <br />