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SUL-04-2007 13:36 Service Station Systems 408 938 SS88 F'.06 Monitoring System Certification FOVAddendutnfor VacuunVPressure Interstitial Sfurs LG 163.1,Enc.It T. Results of Vacuum/Pressure Monitoring Equipment Tesiing 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 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: V Model: ( S • ? System Type: 0 Pressure Vacuum Sensor ID Componcnt(s)Monitored by this Sensor; ,S Sensor Functionality Test Result: Pass; Q Fail Interstitial Communication'rest Result: Pass: ❑ Nail Component(s)Monitored by fhI Sensor: SZ Sensor Functionality Test Result: Pass; f] Fail Interstitial Communication Test Result: Pass; ❑ Fail Component(s)Monitored by this Sensor. 53 Sensor Functionality Test Result: Pass; Ll Fail Iawstidal Communication Test Result: Pass; ❑ Fail 5 Component(s)Mupirored by this Sensor: _ Sensor Functionality Test Result: Pass; Q Fail Interstitial Communication Teal Result: Pass; Q Fail 5 Componentor: Component(s)Monitored by this Sens Sensor Functionality Test Result: Pass; 1] Fall Interstitial Communication Te itResult: Pass: ❑ Fail S Components)Monitored by this Sensor: Sensor Functionality Test Result:2 Pass; ❑ Fail Interstitial Communication Test Result: Pass; ❑ Fail 'J Component(s)Monitored by this Sensor: ; 5 / Sensor Functionality Test Result:0Pass; © Pail Interstitial Communication fest Result: Pass; L) Fail Component(s)Monitored by this Sensor; 5 Sensor Functionality Test Result: Pass; 0 Fail Interstitial CommuoicationTest Result: Puss; Q Fail i Component(s)Monitored by this Sensor: 5/0 Sensor Functionality Test Result: Pass; ❑ Fail Interstitial Communication Test Result: Pass; ❑ Fail S I Component(s)Monitored by this Sensor: Sensor Functionality Test Result:1zPass; ❑ Fail Interstitial Communication'Cest Result: Pass; Q Fail How was interstitial communication verified? ❑ Leak introduced at Far End of Interstitia)Space;, ❑ Gauge; ❑ Visual Inspection; ❑ Other(Describe in Sec. J, below) Vacuum wits restored to operating levels in all interstitial spaces: ❑Yes ©No(If no,describe 'i'n.Sec.A below) J. Comments: Page-j—of_ If the sensor successfully detects a simulated vacuunt/pressure leak introduced in the interstitial space at the furthest point from the selsor,vaculuNpressure has been demonstrated to be communicating dtrpughout the interstice: