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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 IDS.+ ..* .d4 dawns e`4i'•? .ia .. -5,d J4 J'�id rA'�IVSA+x +�;,+vi atJ4J ,�Ott Ft 'it',¢;g,'?i i g; u�',✓*_ d `�,`�; d'� k.d�n'ax' �sw'et'a x?s r"ga ,P'.SG ,.P' ..Y.;.isRi : iJ7 8 'J,�.d 1�p;�t�,G dd+ iy�V'�PNp",: �,,J !t J4,fi di `4 f i i 5i 7 , , ':alra'4�� r,y„uP'"t�?'nryu,,,,.,,'a'�+,p++iu+�aa:'.. �;,�,�"• , a=r'aa`:rs',a�„!`�r,u,s�'..i..u,at,,!a+sY;r+'d,��'f;. Component(s) Monitored by this Sensor: FUEL OIL RETURN LINE S1 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: FUEL OIL SUPPLY OIL LINE S2 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: VENT LINE S3 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: REMOTE FILL LINE S4 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail Component(s) Monitored by this Sensor: VENT TRANSITION SUMP -- MAG SENSOR S9 Sensor Functionality Test Result: S. Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: SUPPLY LINE TRANSITION SUMP -- MAG SENSOR S10 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: REMOTE FILL SUMP -- MAG SENSOR S11 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: TANKTOP FILL SUMP -- MAG SENSOR S12 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail Component(s) Monitored by this Sensor: DIESEL TURBINE SUMP -- MAG SENSOR S13 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: THIS SITE HAS SMART SENSOR MAGNESTRICTIVE PROBES ACTING AS SUMP SENSORS age 4 or 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