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►uw13uu ,nsors LG 163-1,Linc. ll I. Results of Vacuum/Pressure Monitoring Equipment Vesting 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: Model: 33opzo r y System Type: ❑ Pressure;M_ACacuum Sensor ID Component(s)Monitored by this Sensor: 07 5 Sensor Functionality Test Result:EX Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail '501 Component(s)Monitored by this Sensor: 87 r .4 Sensor Functionality Test Result: [.Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail Component(s)Monitored by this Sensor: V`r-�- o ti �L I 6 S 5) O Sensor Functionality Test Result:[K Pass; El Fail Interstitial Communication Test Result:E]Pass; El Fail u I l Component(s)Monitored by this Sensor: q 1 I� Sensor Functionality Test Result: Va Pass; ❑ Fail Interstitial Corrununication Test Result:❑Pass; El Fail Component(s)Monitored by this Sensor: Cl (,—S 2 Sensor FunctionalityTest Result: Pass; El Fail Interstitial Communication Test Result:❑Pass; ❑ Fail Component(s)Monitored by this Sensor: l> a 10 L) G 7- 5 ) 3 Sensor Functionality Test Result:IM Pass; ❑ Fail Interstitial Communication Test Result:❑Pass; ❑ Fail 'S Component(s)Monitored by this Sensor: 1D-11--S r l� 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) ,T. Comments: =�S t► [t �+ �- Fla'ZI tz cc) rye,L) 1 0`V-z-Vyu*� � ._ 2- 5� _ S—N_a� r',o►�rw t�1 t��_ 1_� S P--o 2 1-7—�_�� (z �s E S t Page of ENVIRONMENTAL HEALTH DEPARTMENT ' 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.