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Monitoring System Certification Form 'dendum for Vacuum/Pressure Interstitial` ors LG 163-1,Enc.II 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. Manufacturer: — Veeder Root Model: 0330020-496 System Type: ❑ Pressure;® Vacuum Sensor ID Component(s)Monitored by this Sensor: 91 PRODUCT LINE S/N-10460002 S-5 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; El Fail S-6 Component(s)Monitored by this Sensor: 91 VENT LINE S/N-10198 —" 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 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, below) Vacuum was restored to operating levels in all interstitial spaces: ®Yes ❑No(If no, describe in Sec.J, below) J. Comments: REPLACED TWO VACUUM SENSORS, S-5 AND S-6, REPLACED HOSE AND RECONNECTED ALL WIRING IN JUNCTION BOX. TESTED FUNCTIONALITY OF SENSORS AND PERFORMED EVAC HOLD, VERIFIED HIGH LIQUID ALARM AND PLLD SHUTDOWN...ALL OK I�Ws ects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from the sbeen demonstrated to be communicating throughout the interstice.