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Monitoring System Certification Forn Aendum for Vacuum/Pressure Interstitial r 'ors LG 163-1,Enc.II j} 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. Vianufacturer: -VR Model:— TLS 350 System Type: ❑ Pressure; ®Vacuum Sensor ID Component(s)Monitored by this Sensor: —87 LINE Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail Component(s)Monitored by this Sensor: VAPOR LINE Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail Component(s)Monitored by this Sensor: 91 LINE Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail Component(s)Monitored by this Sensor: VENT LINE Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fall 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; 0 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; Q Visual Inspection; ® Other(Describe in Sec.J, below) Vacuum was restored to operating levels in all interstitial spaces: ®Yes ❑No(If no, describe in Sec.J, below) J. Comments: sensor communication verified by sensor going into alarm at the panel 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.