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12/30/2010 14:15 530774499892 MIDVALLEY CONSULTING PAGE 07 Monitoring System Certitk smon Form:Addendum for VacuumiPressure InterstA f Sensors LG 163-1,Enc.II T. Results of Vacunm/Presaure Monitoring Equipment Tenting This page should be used to dootnment 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 VEEDER ROOT Model: system Type:❑Pressure;N Vacuum Sensor ID .:;,�. ..;,._u ,, �, ..+: s � .t,�..4..• n Component(s)Monitored by this Sensor: 87 PRODUCT LINE S1 Sensor Functionality Test Result 9 Pass; ❑ Fail ammsildal Communication Test Result:0 Pass; I] Fail Component(s)Monitored by this sensor, ALL VENTSIVAPOR S 2 Sensor Functionality Test Result 0 Pass; ❑ Fail interstitial Communication Test Resalt:0 Pass; ❑ Fail Componeat(s)Monitored by this Sensor 87 TANK ANNULAR S 3 Sensor Funakmality Test Result:El Pass; ❑ Fait Interstitial Communication Test Result:0 Pass; ❑ FatT Component(s)Monitored by this Sensor. 91 PRODUCT LINE S 4 Sensor Functionality Test Result:®Pass; ❑ Fail interstitial Communication Test Result®Pass; ❑ Fail Componeat(s)Monitored by this sensor. DIESEL/91 TANK ANNULAR S5 Sensor Functionality Test Result:El Pass; ❑ Fail interstitial Communication Test Result.®Pass; ❑ Fail Component(s)MomMered by this Sensor. DIESEL PRODUCT LINE S6 Sensor Functionality Test Result 0 Pass; ❑ Fail interstitial Communication Test Result®Pass; ❑ Fail Components)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass; ❑ Fait Interstitial Communication Test Result❑Pass; ❑ Fail Componeat(s)Monitored by this Sensor Sensor Functionality Test Result.❑Pass; ❑ Fail Interstitial Communication Test Result❑Pass; ❑ Fail Compoment(s)Monitored by this Sensor; Sensor Functionality Test Result:❑Pass; ❑ Fail latwstitial Communication Test Result:❑Pass; ❑ Fail Component(s)Monitored by this Sensor. Sensor Functionality Test Result:❑Pass; ❑ Fail. interstitial Communication Test Result;❑Pass; ❑ Fail Hoa was interstitial communication verified? ® Leak Introduced at Far End of Interstitial Space;' LJ Gane ❑ Visual •tion ❑ Other(Describe in Sec.J below Vacuum was restored to operating levels in all interstitial spaces; ®yes ❑No(tf no, describe in Sec.J,below) J. Comments: Page of ' If the sensor successfully detects a simulated vacuum/pressure leak introduced in the imtentitial space at the furthest point from the sensor,vacuum/Ptessure has been demonstrated to be connmunicating throughout the interstice.