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'law dlonitoringSystem Certiftc: Iinn Form: Addendian for VacuumlPressure Intersti6alSensors LG 163-I. Enc. II 1. Results of Vacuum/Pressure Monitoring Equipment Testing This page should be used to document testing and servicing of Vacuum and pressure interstitial sensors. A copy of this form must be included with the Monitorine System Certification Form, schich must be provided to the tank system oss'ner/operator. The owner/operator must submit a copy of'the Monitoring System Certilicatimi Form to the local agency regulating UST systenis within 30 days of test date. Manufacturer: �- ` Model: ✓ S)'sient Type:❑ Prcssure:z Vacuum Sensor ID Componcnt(s)>lonitored by'this Sensor: 'S Sensor Functionality Test Result:[Pass: ❑ fail Interstitial Communication Test Result;) Pass: ❑ Fail Componengs)Monitored by Ibis Sensor: �?7- Z Sensor Functionality Test Result:,® Pass: ❑ Fail Interstitial Communication Test Result: 'Pass: ❑ Fad S Cumponeni(s)Atonitored M•this Sensor: 87 -v Sensor Functionality Test Result:.®Pass: ❑ Fail luterstitial Communication Test Result:[31iass: ❑ Fail S C/ Componcnt(s),V)oniiored by this Sensor: r Sensor Functionality Test Result:,®Pass: ❑ Fail Interstitial Communication Test Resuh:aPass: ❑ Fail S Cotnponew(s)Monitored be this Sensor: _ Sensor Functionality Test Result:.®Pass: ❑ Fall Interstitial Communication Test Resuluo Pass: ❑ Fail S Contponent(s) )lonilored hp this Sensor: ,D.cs.:< �[7 u- .•! Sensor Functionality Test Result:,Pass: ❑ fail Interstitial Communication Test Result:0 Pass: ❑ Fail Conuponent(s) Monitored by this Sensor: Sensor Functionalin Test Result:❑Pass: ❑ Fail Interstitial Communication Test Result:❑ Pass: ❑ Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass: ❑_Fall Interstitial Communication Test Result: ❑ Pass: ❑ Fail Componem(s)Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass: ❑ Fail Interstitial Communication Test Result:❑ Pass: ❑ Fail Cam pollen I(S).Monitored by this Sensor: Sensor Functionality Test Result:❑Pass: ❑ Fail Interstitial Communication Test Result:❑ Pass: ❑ Fail I lms was itucrs0tial communication verified': ❑ Leak Introduced at Far End of Interstitial Spacer ❑ Gan to ❑ Visual Inspection: ❑ Other f0escribe in.Sec. J. belong Vacuum s.a% restored to operating Icsels in all interstitial spaces: ❑Yes ❑No(ry no. describe in See.J. below) .1. Comments: Page-or- If the sensor successfully detects a simulated vacuumipressure Ical introduced in the intentiiial space at the furthest point from the sensor. vacuum/pressure has been demmtsrated to be communicating throughout the interstice.