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Monitoring System Certification Fora .ddendum for Vacuum/Pressure Interstitia msors 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. 99 SHELL Manufacturer: VEEDER ROOT Model: VPH System Type: ❑ Pressure; ® Vacuum Sensor ID S1 Component(s) Monitored by this Sensor: 87 PRODUCT LINE Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: VAPOR RETURN LINE S2 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: 91 PRODUCT LINE S3 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: 91/87 VENT LINE S4 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s)Monitored by this Sensor: DIESEL PRODUCT LINE S5 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: DIESEL VENT LINE S6 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, belo") Was vacuum/pressure restored to operating levels in all interstitial spaces? ® Yes ❑No (If no, describe in Sec. J below) J. Comments: DIESEL VENT LINE FLOAT WOULD NOT ACTIVATE ALARM. REPAIRED ON SITE TESTED AND PASSED Page 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 wwwmnidocs.org Rev.01/26/06