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Monitoring System Certification For dendum for Vacuum/Pressure Interstitial sors . . 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: TLS350 System Type: ❑ Pressure; ® Vacuum Sensor ID S1 Component(s) Monitored by this Sensor: 87 Product Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail 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 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: 91 Tank ANN S4 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: DIE Product S5 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;' ❑ 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 Product Float switch failed and 420 sensor on 87 ANN failed. *"repairs to be made by Central Petroleum." Page A5 of ' 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.unidoes.org Rev. 01/26/06