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Monitoring System Certification Forendum for Vacuum/Pressure Interstitial rs I Me 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 Form to the local agency regulating UST systems within 30 days of test date. Manufacturer:VEEDER-ROOT Model: TLS 350 System Type: ❑ Pressure;® Vacuum Sensor ID Component(s) Monitored by this Sensor: 87 PRODUCT S1 [E] Fail Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; Component(s) Monitored by this Sensor: 87 TANK ANN S2 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; Fail Component(s) Monitored by this Sensor: 91 PRODUCT S3 ® Fail Sensor Functionality Test Result: F] Pass; ® Fail Interstitial Communication Test Result: ❑ Pass; Component(s) Monitored by this Sensor: DSL PRODUCT S4Sensor 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: F-1 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) Was vacuum/pressure restored to operating levels in all interstitial spaces? ❑Yes ❑No (If no, describe in Sec. J, below) J. Comments: 91 S3 PRODUCT LINE FAILED. WOULD NOT GO INTO NO VAC OR HIGH LIQUID. CAP GLUED SHUT ON HIGH LIQUID SENSOR. NEEDS REPAIRED AND RETESTED ASAP. ** repairs" Page 3 of 5 ' 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. UN-036A-1/1 www.unidocs.org Rev.01/26/06