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9255517889 Line 1 09 19 a.m. 04-01-2011 7/7 ■ 6frTLfR-RYAN INC. GR Job # 10-058090 ivlonitoring System Certification Form:Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1.Enc.II 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 Fonn to the local agency regulating UST systems within 30 days of test date. Manufacturer: Veeder Root Model: 332175-001 System Type: ❑Pressure; ®Vacuum [Sensor ID Component(s)Monitored by this Sensor: 87 Product S-7 Sensor Functionality Test Result: ©Pass; []Fail Interstitial Communication Test Result: ©Pass; ❑Fail Component(s)Monitored by this Sensor: 87 Vent S-9 Sensor Functionality Test Result: ®Pass; ❑Fail Interstitial Communication Test Result: ®Pass; ❑Fail Component(s)Monitored by this Sensor: Vapor Lines S-10 Sensor Functionality Test Result: ©Pass; []Fail Interstitial Communication Test Result: ®Pass; []Fail Component(s)Monitored by this Sensor: 91 Product S-I1 Sensor Functionality Test Result: ©Pass; []Fail Interstitial Communication Test Result: ©Pass; []Fail Component(s)Monitored by this Sensor: 91-Vent S-12 Sensor Functionality Test Result: ©Pass; ❑Fail Interstitial Communication Test Result: ©Pass; []Fail Component(s)Monitored by this Sensor: DSL-Product S-13 Sensor Functionality Test Result: ©Pass; ❑Fail Interstitial Communication Test Result: ®Pass; []Fail Component(s)Monitored by this Sensor: DSL-Vent 5-14 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;(t) []Gauge; ❑Visual Inspection; []Other(Describe in Sec.J, below) Vacuum was restored to operating levels in all interstitial spaces: ©Yes ❑No(lfno,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.