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Monitoring System stem Certification Form Addendum for Vacuum/Pressure Interstitialfetors 2 4 ZW7 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. I Manufacturer: VEEDER ROOT I Model: TLS 350 n System Type: ❑ Pressure; ® Vacuum I Sensor ID J. Comments: Country Club Circle K ALL PASSED 1-23-2017 Functionality Passed - No Communication done - no test ports. Page 4 of 4 ' 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 Component(s) Monitored by this Sensor: 87 PRODUCT S1 Sensor Functionality Test Result: ®Pass; El Fail Interstitial Communication Test Result: ®Pass; ❑Fail Component(s) Monitored by this Sensor: 87 TANK ANNULAR S2 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail How was interstitial communication verified? Component(s) Monitored by this Sensor: 91 PRODUCT below S3 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: 91 TANK ANNULAR S4 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: DIESEL 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: Ranenr Fnnctinnnlity Test Resnit F-1 Pass' n Fail interstitial Communication Test Result: n Pass: n Fail J. Comments: Country Club Circle K ALL PASSED 1-23-2017 Functionality Passed - No Communication done - no test ports. Page 4 of 4 ' 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 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: Country Club Circle K ALL PASSED 1-23-2017 Functionality Passed - No Communication done - no test ports. Page 4 of 4 ' 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