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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors ?-7?00 S 1. Results-of Vacuum/Pressure 1%, Atoning Equipment Testing 57-K.J. 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 agicy regulating UST systems within 30 days of test date. _ Manufacturer: ��, �� Model: L5. 3 So System Type: ❑ Pressure; Vacuum Sensor ID Component(s)Monitored by this Sensor: g'T Qgj ul.- a<-- lj I Sensor Functionality Test Result: X Pass; Fail Interstitial Communication Test Result: SC Pass; _ Fail Component(s)Monitored by this Sensor: (��P 2 -ter► �,� 5 Sensor Functionality Test Result: & Pass; Fail Interstitial Communication Test Result: Pass; _ Fail Component(s)Monitored by this Sensor: ( u`-1 rj �j Sensor Functionality Test Result: /\ Pass; Fail Interstitial Communication Test Result: _ Pass; .__ Fail Component(s)Monitored by this Sensor: Oil i L4 14f- SensorFunctionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail Component(s)Monitored by this Sensor: � I tJ�J Sensor Functionality Test Result: )r\ Pass; Fail Interstitial Communication Test Result: Pass; ._ Fail Component(s)Monitored by this Sensor: t L E 5 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 Hoi was interstitial communication verified? 7 j eak 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? +Q/Yes ❑No(If no, describe in Sec.J, below) J. Comments: 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.