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U11ZY1;LULU FRI 1b: L4 FAX LU`J4bb.S433 aJt; ZMW vfotiitoring System Certification Norm' ddenduni fet- Vactium/l'ressur-e lnterstitial sors 1. Results of Va cu um/1'ress tire Monitoring Equipment Testing This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of' this forin mast be included with the Monitoring System Certification Form, which must be provided to the tank system owner/operator. `l -he owner/operator must submit a copy of the Monitoring System Certification Forin to the local agency regulating USI' systems within 30 days of test date. Manufacturer: VEEDER ROOT Model: TLS360 System Type: ❑ Pressure; ED Vacuum Sensor ID Cornlsonent(s) Monitored by this Sensor: 87 LINE S _ Sensor f=unctionality Test Result; Z Pass; ❑ Fail Interstitial Commun!cat ion.'fe_st Result: ®Pass; [j 1 a_il ' Component(s) Monitored by this Sensor: VAPOR LINE -^ Sensor Functionality Test Result. ® Pass; ❑ Fail Interstitial Comtnunicatio_n Test Result: ® Pass; ❑ fail Component(s) Monitored by this Sensor: 91 UNE .! S3 _ Sensor Functionality Test Result: 2 Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; •- Fait Cornponent(s) Monitored by this Sensor: VENTS _❑ sa Sensor Functionality 'Fest Result: ®Pass; ❑Fail Interstitial Communication Test Result: ® Pass, ❑ F_ail Component($) Monitored by this Sensor: —I Sensor FunctionalityTest Result: Pass; ❑ ❑Fail Interstitial Communication "l'esi Result: ❑Pass; ❑ Paii Cornponent(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail _Interstitial Communication Test Result: El Pass; EL Fail-' Component(s) Monitored by this Sensor: Y^^ Sensor Punctionality'l-cst Result: ❑ Pass; Q Fail Interstitial Communication Tcst Result: ❑ Pass; ❑ Fttii ' Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication 'fest Result: ❑ Pass; Pa;l Component(s) Monitored by this Sensor: _❑ ^ Sensor Functionality "fest Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; Fail _ Components) Monitored by this Sensor:— _❑ Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail _ HOW was interstitial corntnunication verified'.' _❑ teak Introduced at Far End of Interstitial Space;' ❑ Gauge; ® Visual Inspection; ❑ Other (Describe in Sec. J, below) 1 Was vacuum/pressure restored to operating levels in all intcrstitial spaces" Z Yes ❑ No (If no, clescribe in Sec../, below) J. Comments: Page 4 of 4 ' If the sensor successfully detects a sitmllated vacuum/pressureleak introduced in the interstitial space at the furthest point from the sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice. LIN -036A - 1/1 wwwa mwocs.org lice. 03/26/00 L000190001M 9TTO t tL 60Z XV,3 5T:9T OTOZ/80/ZO