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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 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 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;1 ❑ 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: CA FUEL 2575_f OITNTRV f T,TTR BI VD STOCKTON CA 95204 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.unidoes.org Rev.01/26/06