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Monitorial;System Certification Form, ,Iendum for Vacuum/Pressure Interstitial.' ors SEP 21 1015 I. Results of Vacuum/Pressure Monitoring Equipment Testing rrAA''``'' pEPn2A' This page should be used to document testing and servicing of vacuum and pressure interstitt�l'�1I6iE�lA`�FW%t- � form must be included with the Monitoring System Certification Form, which must be provillff o I e tsystem 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:TLS-350 System Type: ❑ Pressure; ® Vacuum Sensor ID S - 1 Component(s) Monitored by this Sensor: 87 PRODUCT LINE Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail S -2 Component(s)Monitored by this Sensor: VAPOR RETURN LINE Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail Component(s)Monitored by this Sensor: 91 PRODUCT LINE S -3 Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail S -4 Component(s)Monitored by this Sensor: 87/91 VENT LINES Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail S -5 Component(s)Monitored by this Sensor: DIESEL PRODUCT LINE Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail S -6 Component(s)Monitored by this Sensor: DIESEL VENT LINE 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 Functiop_ality 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 Components)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) Was vacuum/pressure restored to operating levels in all interstitial spaces? ® Yes ❑No (If no, describe in Sec. J, below) J. Comments: 99 Shell 7700 Moreland Rd Stockton 8-25-15 ALL PASSED Page 4 o ' 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. UN-036A-1/1 www.unidocs.org Rev.01/26/06