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1 <br /> Fast Lane Central Valley, 116 East Roth Rd, Lathrop, CA 95330 6/20/201:7 (Truck) <br /> Monitoring System Certification Form: Addendum foi-Vacuum/Pressure Interstitial Sensors <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 iEopy of this form must be included <br /> with the Monitoring System Certification Form,which must be provided to the tank system owner/operator.The ownerioperator must submit a <br /> copy of the Monitoring System Certification Form to the local agency regulating UST systems within 30 days of test date. <br /> Manufacturer: Veeder Root Model: System Type: ❑ Pressure; ❑Vacuum <br /> Sensor ID <br /> Component(s)Monitored by this Sensor: Diesel South Piping` <br /> S1 <br /> Sensor Functionality Test Result: 21 Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; Fail <br /> Component(s)Monitored by this Sensor: Diesel South Vent Line <br /> 52 <br /> Sensor Functionality Test Result: ❑ Pass; Q Fail Interstitial Communication Test Result: El Pass; El Fail <br /> Component(s)Monitored by this Sensor: Diesel North Piping <br /> S3 <br /> Sensor Functionality Test Result: El Pass; Q Fail Interstitial Communication Test Result: ®Pass; Fail <br /> Component(s)Monitored by this Sensor: Diesel North Vent Line <br /> S4 <br /> Sensor Functionality Test Result: ❑✓ Pass; El Fail Interstitial Communication Test Result:E]Pass; Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: 0 Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: Pass; Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: El Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; El Fail <br /> Comp <br /> onent(s) itored by this Sensor: <br /> SensTest Result: ❑Pass; ❑ Fait Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> now was interstitial communication verified? <br /> ❑ Leak.Introduced at Far End of Interstitial Space-,' ❑ Gauge; ❑ Visual Inspection; ❑ Other(Describe in Sec.J,below) <br /> Was vacuum/pressure restored to operating levels in all interstitial spaces? ❑ Yes ❑No (If no, describe in See. J, below) <br /> J. Comments: Couldn't get high liquid on s2 and s3 alarms; <br /> piping runs can't be checked because no valve arm in dispenser. <br /> 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 /> www.unidocs.org <br />