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Monitdring System Certification Form: endum for Vacuum/Pressure Interstitial Mrs <br /> I. Results of Vacuum/Pressure Monitoring Equipment Testing <br /> This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of <br /> this form must be included with the Monitoring System Certification Form, which must be provided to the tank <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: ❑Pressure; ®Vacuum <br /> Elm 1 <br /> r <br /> sor ID <br /> Component(s)Monitored by this Sensor: FUEL OIL RETURN LINE <br /> S1 ❑ Fail <br /> Sensor Functionality Test Result: ®Pass; El Interstitial Communication Test Result: ®Pass; <br /> Component(s)Monitored by this Sensor: FUEL OIL SUPPLY OIL LINE <br /> S2 <br /> Sensor Functionality Test Result: ®Pass; El Fail Interstitial Communication Test Result: ®Pass; Fail <br /> Component(s)Monitored by this Sensor: VENT LINE <br /> S3 ❑ <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ®Pass•, Fail <br /> Component(s)Monitored by this Sensor: REMOTE FILL LINE <br /> S4 <br /> Sensor Functionality Test Result: ®Pass; E] Fail Interstitial Communication Test Result:®Pass; Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: El Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> How was interstitial communication verified? <br /> ❑ Leak Introduced at Far End of Interstitial Space;' ❑ Gauge; ® Visual Inspection; ❑ Other(Describe in Sec.J, below) <br /> Was vacuum/pressure restored to operating levels in all interstitial spaces? ®Yes ❑No(If no, describe in Sec.J, below) <br /> J. Comments: Lodi Memorial Hospital 10-9-13 <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 />