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. 1 0 0 Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors 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 a2encv reRulatinR UST systems within 30 days of test date. Manufacturer: VEEDER ROOT Model: TLS 350 System Type: ❑ Pressure; ® Vacuum Uu k f 9 f.✓E' 1�,! Af df E�N.fi f` 3s�A }'i �a t 7V 1! ' in J""�`AF f i f f f f D ' N .,� /,i y�8 6 u. iJP ' [ FN t�.3' i,r Y d- t J , J3 �' T�f $ ?�W r �—, ry Sensor Il)s `i.,u�.s�i t 9 N.y�1i }n �d��:, ��?� ,tai. I'ff i� u•� J�P�; IJ .r!r i Ai�lr.�i :� f.�, ,.�J Component(s) Monitored by this Sensor: 87 PRODUCT S1 Sensor Functionality Test Result: ❑ Pass; ® 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 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 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: 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: S1 WAS IN ALARM AT ARIVIAL OF TEST. I WAS UNABLE TO FIX, TO BE REPAIRED & RETESTED BY CENTRAL PETROLEUM. 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