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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors I. 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 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. J. Comments: DURING TESTING S-2, S-4 & S-5 ALL IN NO VAC, FUNCTIONALITY TESTING CANNOT BE PERFORMED IF VACUUM CANNOT BE REPRODUCED Page 4 of 4 ' If the sensor successfully detects a simulated vacuum /pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. UN - 036A. it wTnv.unidocs.org Rev0 01/26/06 Manufacturer: VEEDER ROOT Model: TLS -350 System Type: ❑ Pressure; ® Vacuum Sensor ID Component(s) Monitored by this Sensor: DIESEL TANK 1 - D T - 1 - PRODUCT LINE S - 1 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: DIESEL TANK 1 - D T -1 - SYPHON LINE S-2 Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: DIESEL TANK 1 - D T -1 as VENT LINE S-3 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: DIESEL TANK 2 - D T - 2 - PRODUCT LINE S - 4 Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: DIESEL TANK 2 - D T as 2 - VENT LINE S - 5 Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: GAS TANK 1 - G T no 1 - PRODUCT LINE S-6 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: GAS TANK 1 - G T - 1 - VENT LINE S - 7 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: GAS TANK 1 - G T -1 - VAPOR RETURN LINE S - 8 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Monitored by this Sensor: [EComponent(s) Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: ll Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail 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 no, describe in Sec. J, belotii) J. Comments: DURING TESTING S-2, S-4 & S-5 ALL IN NO VAC, FUNCTIONALITY TESTING CANNOT BE PERFORMED IF VACUUM CANNOT BE REPRODUCED Page 4 of 4 ' If the sensor successfully detects a simulated vacuum /pressure leak introduced in the interstitial space at the furthest point from the sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. UN - 036A. it wTnv.unidocs.org Rev0 01/26/06