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�- - _... a -wl LU W-1,Enc. 1]( 1. 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. Manufacturer: vkr—taC-7Z C1C. Model: ,33op2<Dr �,A b System Type: ❑ Pressure;0_1�_Vacuum Sensor ID Component(s)Monitored by this Sensor: 'y �2O1� T � f S Sensor Functionality Test Result: EX Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fai I S J Component(s)Monitored by this Sensor: 87 v L Aj r U'.C — Sensor Functionality Test Result: [,Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass-, ❑ Fail Component(s)Monitored by this Sensor: VX4.-Pc� R L I N S 5 Sensor Functionality Test Result: Pass; tY (,� ❑ Fai! Interstitial Communication Test Result: ❑ Pass; El Fail I 1 Component(s)Monitored by this Sensor: Cl ! P2 0 67v tcz r Sensor Functionality"Test Result: 2�Pass; ❑ Fail Interstitial Corrununication Test Result: ❑ Pass, ❑ Fail Component(s) Monitored by this Sensor: Lr S )2— Sensor FunctionalityTest Result: [ Pass; E] Fail Interstitial Communication Test Result: LJ Pass; F1 Fail Component(s)Monitored by this Sensor: t> C— IS 3 0 � Sensor Functionality Test Result: I Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s)Monitored by this Sensor: 0 a S ,_- ►V "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; ❑ 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) Vacuum was restored to operating levels in all interstitial spaces: Yes ❑No (If no, describe in Sec. J, below) I Comments: J_>�t�c�S i 1 Tl L edzt tzF Co v--t rm L)V.)% o�,4_ jM5 TE 01 Q U t= T7� S c.r�f'� Nc�'r` P o r.�Tl4 l tV 1 1�n 1 t3 "S P--O T— 0,3 R iVlEl� '� W 20 i r Page of ENVIRONMENTAL HEALTH GERARTMENT + 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.