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From: 08/28/2(k13- 2 0843 P-006/00P. w L) Monitoring System Certification Form:Addendum for Vacuum/pressure Interstitial Sensors I. Results of Vacuum/Pressure Monitoring Equipment Testing SEP 2 S 2017 This page should be used to document testing and servicing of vacuum and presstrtF 1.nterstitial sensors.:A copy of this form must be included with the Monitoring System Certification Form, whichmust he 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: System Type:❑Pressure;®Vacuum Sensor HI Component(s)Monitored by this Sensor: Diesel 1 Product-Siphons1 Sensor Functionality Test Result Pass; ty ® El Fail Interstitial Communication Test Result:®Pass; [I Fail Component(s)Monitored by this Sensor: Diesel 2 Middle s2 Sensor Functionality Test Result:®Pass; ❑ Fail Interstitial Communication Test Result:®Pass; ❑ Fail Component(s)Monitored by this Sensor: Vents ! s3 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; ❑ Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail Composent(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; ❑ Fail 1 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; ❑ Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail gv How was interstitial communication verified? ® Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ® Visual Inspection; ❑ Other(Describe in Sec.J,below) Was vacuum/pressure restored to operating levels in all interstitial spaces? ®Yes ❑No(If w,describe in Sec.J, below) J. Comments: Page 1 of 1 If the sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the fii thest point from the > sensor,vacuum/pressure has been demonstrated to be communicating throughout the interstice. *' UN-036A-1/I www.unidocs.org Rev.01/26/06