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F / GFTTIFB-RYAN INC. i LLGR Job # 2Q-XXXXXX ® s Monitoring System Certification Form:Addendum for Vacuum/Pressure Interstitial Sensors IVi/-'R V 9 2017 LG 163-1.Enc.II I Results of Vacuum/Pressure Monitoring Equipment Testing pressut - ititerstifW sensors. A copy of This page should be used to document testing and servicingVv�tlrtiM'Iif#1 0: this form must be included with the Monitoring System Certification[>F`#, which t 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. Manufacturer: System Type: Pressure; Vacuum Sensor ID b: omponent(s)Monitored y thisSensor: 1 t 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; DFail 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; OF" 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 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;(1) Gauge; isual Inspection; Other(Describe in Sec.J, below) Vacuum was restored to operating levels in all interstitial spaces: []Yes []No(Ijno,describe in Sec.J,below) J. Comments: Page of (1) 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.