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Nov 04 10 07:33a Elite ?V Contactors 12094615342 p.5 <br />Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors <br />1. Results of Vacuum/Pressure Monitoring Equipment Testing <br />This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of this <br />form must be included with the Monitoring System Certification Form, which must be provided to the tank system <br />owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form to the local <br />agency regulating UST systems within 30 days of test date. <br />Manufacturer: ���'( � `Cot <br />Model: O —��3 System Type: Pressure- LAr '7r Vacuum <br />Sensor ID <br />.. <br />SSensor <br />Component(s) Monitored by this Sensor: Z-7 LAnc, <br />Functionality Test Result: .Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br />Component(ls) Monitored by this Sensor: * i' , <br />eS <br />Sensor Functionality Test Result: 0 Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br />Component(s) Monitored by this Sensor: Cf ne <br />Sensor Functionality Test Result: Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br />S <br />Component(s) Monitored by this Sensor: Vent <br />Sensor Functionality Test Result: [,Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br />i <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br />Component(s) Monitored by this Sensor: <br />Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br />How was interstitial communication verified? <br />❑ Leak Introduced at Far End of Interstitial Space;` ❑ Gauge; ❑ Visual Inspection; ❑ Other (Describe in Sec. J, <br />below <br />W: as vacuum/pressure restored to operating levels in all interstitial spaces? ❑Yes ❑ leo (If no, describe in Sec -1, below) <br />J. Comments: <br />Page 4 of 4 <br />` If the sensor successfully detects a simulated vacuum/pressureleak introduced in the interstitial space at the furthest point from the <br />sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. <br />UN -036A - 111 www.unidoc"rg Rev. 01126/06 <br />