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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors L. ' D I. Results of Vacuum/Pressure Monitoring Equipment Testing SEP 19 2014 This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A co of this form must be included with the Monitoring System Certification Form, which must br��4WiQt'b1:'the 4anssALTIN owner/operator. The owner/operator must submit a copy of the Monitoring System CertificatiUu_F riri"iiiYthOIbcal agency regulating UST systems within 30 days of test date. Manufacturer:VEEDER ROOT Model:TLS-350 System Type: ❑ Pressure; ® Vacuum IZ Sensor ID Component(s)Monitored by this Sensor: 87 PRODUCT LINE S-1 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; ❑ Fail Component(s)Monitored by this Sensor: VAPOR RETURN LINE S -2 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 Component(s)Monitored by this Sensor: 87/91 VENT LINES S -4 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: DIESEL PRODUCT LINE S -5 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: DIESEL VENT LINE S -6 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) Was vacuum/pressure restored to operating levels in all interstitial spaces? ®Yes ❑No (If no, describe in Sec. J, below) J. Comments: 99 Shell 7707 Moreland Ct Stockton 8-25-14 age 4 of 4 ' If the sensor successfully detects a simulated vacuum/pressureleak 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