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Monitoring System Certification Form: Ack—,idum for Vacuum[Pressure Interstitial Sen. <br /> I. 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: TLS 350 System Type: ❑ Pressure; ® Vacuum <br /> Sensor ID <br /> Component(s) Monitored by this Sensor: 87 LINE <br /> 51Sensor Functionality Test Result: ® Pass; E] Fail Interstitial Communication Test Result: ®Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: VAPOR - <br /> S2Sensor Functionality Test Result: ® Pass; ElFail Interstitial Communication Test Result: ® Pass; ❑ Fail <br /> Component(s) Monitored by this Sensor: 91 LINE - <br /> S3 - <br /> Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; Fail <br /> ­ <br /> Component(s) <br /> Component(s)Monitored by this Sensor: 87 91 VENTS <br /> S4 <br /> Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; E] Fail <br /> Component(s)Monitored by this Sensor: DIESEL LINE -- <br /> S5 ❑ Fail <br /> Sensor Functionality Test Result: ❑ Pass; ® Fail Interstitial Communication Test Result: ® Pass; <br /> Component(s)Monitored by this Sensor: DIESEL VENT - <br /> S6 - - <br /> Sensor Functionality Test Result: ® Pass; El Fail Interstitial Communication Test Result: ® Pass; F-ai.l <br /> Component(s)Monitored by this Sensor: <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 /> Component(s)Monitored by this Sensor: - <br /> Sensor Functionality Test Result: ❑ Pass; E] Tail 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? ® Visual Inspection; ❑ Other(Describe in Sec. J, below) <br /> ❑ Leak Introduced at Far End of Interstitial Space; Gauge; -Was vacuum/pressure restored to operating levels in all interstitial spaces? ® Yes ❑No(If no, describe in Sec. J, be/otir) <br /> J. Comments: S5 VAC SENSOR WORKED, BUT FLOAT SWITCH DID NOT _ <br /> Ott YYlC., ----- <br /> Page 4 of 4 <br /> 1 sensors sensor successfully <br /> been demoristr demonstrated to be cormmunileak <br /> at ng throughout tlieenterstice�al space at the furthest point from the <br /> LIN-036A-1/1 <br /> www.unidocs.org Re..01/26/06 <br />