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Monitoring System Certificat[on Form:Addendum for Vacuum/Pressure Interstitial Sensors 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. IManufacturer: VEEDER ROOT Model:—463 System Type: ❑Pressure;®Vacuum i Sensor ID Component(s)Monitored by this Sensor: 87 PROD --S1 Sensor Functionality Test Result:®Pass; ❑ Fail Interstitial Communication Test Result:®Pass; ❑ Fail —S2 Component(s)Monitored by this Sensor: 87 VENT Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result:®Pass; ❑ Fail Component(s)Monitored by this Sensor: 87 ANN —S3 Sensor Functionality Test Result:®Pass; ❑ Fail Interstitial Communication Test Result:®Pass; ❑ Fail Component(s)Monitored by this Sensor: 87 VAPOR E S4 Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result:®Pass; ❑ Fail f Component(s)Monitored by this Sensor: 91 PROD --S5 Sensor Functionality Test Result: ®Pass; ❑ Fail interstitial Communication Test Result:®Pass; ❑ Fail Component(s)Monitored by this Sensor: 91 VENT S6 Sensor Functionality Test Result: ❑Pass; ® Fail Interstitial Communication Test Result:❑Pass; ® Fail Component(s)Monitored by this Sensor: DSL PROD i --S7 Sensor Functionality Test Result:❑Pass; ❑ Fail Interstitial Communication Test Result:❑Pass: ❑ Fail f Component(s)Monitored by this Sensor: DSL VENT j [ --S9 Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result:®Pass; ❑ Fail { Component(s)Monitored by this Sensor: DSL-91 ANN ` --S10 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 i How was interstitial communication verified? ' ® leak Introduced at Far End of Interstitial Space;I ❑ Gauge; ® Visual Inspection; ❑ Other(Describe in Sec.J,below) i Vacuum was restored to operating levels in all interstitial spaces: ®Yes ❑No(If no, describe in Sec.J, below) J. Comments: S6 FAILED HIGH LIQUID TEST - i If tho sensor suc ly 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. I i