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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1,Enc.II <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 <br /> this form must be included with the Monitoring System Certification Form, which must be provided to the tank <br /> system owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form to the <br /> local agency regulating UST systems within 30 days of test date. <br /> Manufacturer: VEEDER ROOT Model: 463 System Type: ❑Pressure;®Vacuum <br /> Sensor ID <br /> S1 Component(s)Monitored by this Sensor: 87 PROD_ <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result:®Pass; ❑ Fail <br /> S2 Components)Monitored by this Sensor: --87 VENT <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result:®Pass; ❑ Fail <br /> S3 Component(s)Monitored by this Sensor: 87 ANN <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result:®Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: 87 VAPOR <br /> S4 <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> S5 Component(s)Monitored by this Sensor: 91 PROD <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: 91 VENT <br /> S6 <br /> Sensor Functionality Test Result:❑Pass; ® Fail Interstitial Communication Test Result:❑Pass; ® Fail <br /> S7 Component(s)Monitored by this Sensor: DSL PROD <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: DSL VENT <br /> -S9 <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> 10 Component(s)Monitored by this Sensor: DSL-91 ANN <br /> S <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,below) <br /> Vacuum was restored to operating levels in all interstitial spaces: ®Yes ❑No(If no, describe in Sec.J, belola-) <br /> J. Comments: S6 FAILED HIGH LIQUID <br /> TEST <br /> 'A w4 <br /> � 0 rt� <br /> ENV!MONMENTAL <br /> F1r I TL-1 DFS"° ''_ <br /> -7, , 7 <br /> If the sensor suc ly detects a simulated vacuum/pressure leak 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 />