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Monitoring System Certification Form:Addendum for Vacuum/Pressure Interstitial Sensors <br /> NOV 10 2014, <br /> I. Results of Vacuum/Pressure Monitoring Equipment Testing <br /> s <br /> This page should be used to document testing and servicing of vacuum and pressure if'6h i or s'-`,`A:-,bdp�'-ALTI H <br /> this form must be included with the Monitoring System Certification Form, which must be,,'prqvided-1--'t9,-the=Lank <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:TLS350 System Type: El Pressure; 0 Vacuum <br /> Sensor ID <br /> Component(s)Monitored by this Sensor: FUEL OIL RETURN LINE <br /> S1 <br /> Sensor Functionality Test Result: ®Pass; El Fail Interstitial Communication Test Result: ®Pass; El Fail <br /> Component(s)Monitored by this Sensor: FUEL OIL SUPPLY OIL LINE <br /> S2 Sensor Functionality Test Result: Z Pass; El Fail Interstitial Communication Test Result: Z Pass; 0 Fail <br /> Component(s)Monitored by this Sensor: VENT LINE <br /> S3 Sensor Functionality Test Result: Z Pass; El Fail Interstitial Communication Test Result: Z Pass; El Fail <br /> S4 Component(s)Monitored by this Sensor: REMOTE FILL LINE <br /> Sensor Functionality Test Result: Z Pass; El Fail Interstitial Communication Test Result: Z Pass; El Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: D Pass; El Fail Interstitial Communication Test Result: El Pass; El Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: El Pass; El Fail Interstitial Communication Test Result: 0 Pass; El Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: El Pass; El Fail Interstitial Communication Test Result: 0 Pass; El Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: El Pass; El Fail Interstitial Communication Test Result: 0 Pass; El Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: El Pass; El Fail Interstitial Communication Test Result: El Pass; D Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: D Pass; El Fail Interstitial Communication Test Result: D Pass; El Fail <br /> How was interstitial communication verified? <br /> El Leak Introduced at Far End of Interstitial Space;' [:1 Gauge; Z Visual Inspection; El Other(Describe in Sec. J, below) <br /> Was vacuum/pressure restored to operating levels in all interstitial spaces? Z Yes F]No(If no, describe in See.J, below) <br /> J. Comments: Lodi Memorial Hospital 10-9-14 Lodi CA <br /> Page 4 of 4 <br /> If the sensor successfully detects a simulated vacuum/pressure leak 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 />