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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors HECEIVEL I. Results of Vacuum/Pressure Monitoring Equipment TestingAPPRR 2 0 2015 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 providegl#T 1101�aiiN.1 A! owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form tot I T agency regulating UST systems within 30 days of test date. Manufacturer: VEEDER ROOT Model: TLS -350 — System "I'Npe: ❑ Pressure; ® Vacuum Sensor IU Component(s) Monitored by this Sensor: 87 PRODUCT LINE S 1 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: VAPOR RETURN LINES S 2 Sensor Functionality Test Result: ❑ Pass; ® Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: 91 PRODUCT LINE S 3 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: VENT LINES S 4 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: 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, belolt) Was vacuum/pressure restored to operating levels in all interstitial spaces? ® Yes ❑ No (/f no, describe in Sec. J, beloit) J. Comments: S-2 LIQUID SENSOR NOT FUNCTIONING - ELITE IV TO REPAIR AND TEST. If the sensor successfully detects a simulated 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. UN -036A- 1/1 www.unidocs.org Rev. 01/26/06