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RE <br /> Monitoring System Certification Formdendum for Vacuum/Pressure Interstitial ors CEIVED <br /> . <br /> FEB 2 7 Z01-1 <br /> I. Results of Vacuum/Pressure Monitoring Equipment Testing <br /> This page should be used to document testing and servicing of vacuum and pressure inte l i-d ALT <br /> this form must be included with the Monitoring System Certification Form, which must be pr .y I _, <br /> system owner/operator. The owner/operator must submit a copy of the Monitoring System Certification Form to the <br /> local agency regulating UST systems within 30 days of test date. <br /> Manufacturer:VEEDER ROOT Model:TLS 350 System Type: ❑ Pressure;®Vacuum <br /> Sensor ID <br /> Component(s)Monitored by this Sensor: 87 PRODUCT <br /> S1 <br /> Sensor Functionality Test Result: ® Pass; El Fail Interstitial Communication Test Result: ®Pass; EJ Fail <br /> Component(s)Monitored by this Sensor: 87 TANK ANNULAR <br /> S2 <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass; El Fail <br /> Component(s)Monitored by this Sensor: 91 PRODUCT <br /> S3 <br /> Sensor Functionality Test Result: ®Pass; El Fail Interstitial Communication Test Result: ®Pass; El Fail <br /> Component(s)Monitored by this Sensor: 91 TANK ANNULAR <br /> S4 <br /> Sensor Functionality Test Result: ® Pass; El Fail Interstitial Communication Test Result: ®Pass; El Fail <br /> Component(s)Monitored by this Sensor: DIESEL PRODUCT <br /> S5 <br /> Sensor Functionality Test Result: ®Pass; El Fail Interstitial Communication Test Result: ® Pass; El Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑ Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> rEl�i <br /> w was interstitial communication verified? <br /> How <br /> Introduced at Far End of Interstitial Space;' ❑ Gauge; ® Visual Inspection; ❑ Other(Describe in Sec. J, below) <br /> Was vacuum/pressure restored to operating levels in all interstitial spaces? ®Yes ❑No(If no, describe in Sec. J, below) <br /> J. Comments: Country Club Circle K <br /> AL 1-23-2017 - tion - <br /> Repair and retest to be done by MVP. <br /> Page 4 of 4 <br /> ' If the sensor successfully detects a simulated vacuum/pressureleak introduced in the interstitial space at the furthest point from the <br /> sensor,vacuum/pressure has been demonstrated to be communicating throughout the interstice. <br /> UN-036A-1/1 www.unidocs.org Rev.01/26/06 <br />