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10/06/2011 08:12 2099316743 Waterloo Food Mart Nov 04 10 07:33a Elite Contactors 120946' 42 Monitoring System Certification Form. Addeodum for FScuum/Pressure interstitial Sensors L Results of Vaeunm -Pressure Mouitoriug Egttipment Testing #0720 P.013/015 P•5 This page would be used to document testing and servicing of vacltuZ-n and prcasum inwrz�tiLhd sc it3v1S. A copy of this form must be included with tine Monitoring System Certification Fom-, which trust be pro -tided to the tank system oarner/operator. The oQvner/operator must submit a copy of the Monitoring System Cwifioation Form to the local agency regulating UST systems witWa 30 days of test date. Manufacturer- � �' � (;� IYlodel: O "�FVj J System Type. ❑ Pressure; Vacuum g... Z ,, _ �.i,, :. L t' - •��- .e' � ..t.. - 1,F. - Tr:, t. ' a -r1. L' "5, �- `" i �ri4, .,:iH Component(s) Monitored by this Seusor- ' _ Sensor Functionality Test Result: C2�Pass; ❑ Fail Imerstitial Comtnuaication Test Rt*ult; ❑ Pass; ❑ Fail Corapocent(s) Monitored by this Sensor: O f 0A Sensor Functionality Test Result. (� Pass; ❑ Fail Interstitial Cor=unication Tost Result; ❑ Pass; ❑ Fail C Components) ?monitored by this Sensor: q L.kf\e, r� Scnsor Functionality Tem Result: W Pass; Lj Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Cowponent(s) Monitored by this Sensor: 'Vent 3 Sensor Functionality Test Result: ,Pass; ❑ Fail Inte:rctitial C ommunir-ation Tc_ct Rc.adt: ❑ Paw. ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result; C] Pass; [i Fail interstitial Communication Test Result: ❑ Pass; ❑ Fail Companent(s) Monitored by this Sensor: Sensor Functionality Tcst N;=l : Q Pass; ❑ Fail Inter3titial Communioauon Test Rwult: ❑ Pwo; ❑ Fail Component(s) Monitored by this Sensor: Seinsor Functionality Test Result,. ❑ Pass; ❑ Fail Interstitia.] Communication Test Result: ❑ Pass; ❑ Fail Component(s) monitored by this Sensor: 3t;HS(A FULIGGvsiality TSE R.qult_ ❑Pam; ❑ Paii Itxctat UeJ CUULiUU1dUdLiUlL Tcst RcaulL {] Past; ❑ rr-4v Component(s) Monitored by this Sensor. Soasor Functionality Ttst Result. ❑ Pass; Q Fail Interstitial Cozmmunieation Test Result: ❑ Pass; © Fait Component(s) Monitored by this Sensor: Sensor rrmctionaiity Test Result: ❑ Pass; ❑ Fail trnterstitial Comnnin;cation Test Result_ ❑ Pass; ❑ Fail How was interstitial communication verified? C1 P.eak )htroduced at Far End of Interstitial Space;' ❑ Creuge; ❑ Visual Insp=ion; ❑ Other (Describe in Sec. J, below) VVas vacuemJpressure restored to operating levels iQ all ictet pdtitial spaees? ❑ Yes ❑ i\o (f no, describe in Sec_ .T below) J. Comynents: Page 4 of 4 ` If the sensor succcssfally detects a simulated 'vaeuumlpressureleak intt1roduced in theinterstitial space at the Azahest point from the sensor, vacuurn/premtre has been dernonstrated to be communicating througbout the interstice. UN -43,6A - lil www_avidomot'-, Rev_ 01/ 606