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Nln,nitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors LG 163-I, Enc. 11 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: 463 System TNpe: ❑ PreSSUre:Q kacuum Sensor ID Component(s) Monitored by this Sensor: ;1, '►r l. G.S- ! ;_aG �'v S_;t.': -- Sensor Functionality Test Result: Q Pass; ❑ Fail Interstitial Communication Test Result: ® Pass, ❑ Fail Component(s) Monitored by this Sensor: L- Sensor Functionality Test Result: IN Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass. ❑ Fail Component(s) Monitored by this Sensor: (u'i }an 1) V k" Sensor Functionality'rest Result:IqPass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s)Monitored by this Sensor: '—I LN Sensor Functionality Test Result: Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass: ❑ Fail Component(s)Monitored by this Sensor: Cl 7t_G `, .4 S�_ Sensor Functionality'rest Result: Pass: ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s)Monitored by this Sensor: Ct ( \^"4. _ Sensor Functionality fest Result: Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass, ❑ Fail Component(s)Monitored by this Sensor: c-1- _ Sensor Functionality Test Result: Pass: ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s)Monitored by this Sensor: vv•, Sensor Functionality lest Result: Pass: ❑ Fail Interstitial Communication Test Result: ❑ Pass: ❑ Fail Component(s) Monitored by this Sensor: Sensor Functionality Test Result: Pass-, ❑ Fail 1 terstitial Communicatiot Test Result:❑ Pass: ❑ Fail Component(s) Monitored by this Sensor: 1�J 14^,�` t•. 5( (� Sensor Functionality Test Result: OR 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 inSec.,/ helrnr) Vacuum was restored to operating levels in all interstitial spaces: ®Yes ❑ No!/f no, describe in.Sec.J, below) J. Comments: L i'a 1/.i is`a %11i LAI! Page of ' !f 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.