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Monitoring System Certification Form: Aondum for Vacuum/Pressure interstitial W-UtIVED L Results of Vacuum/Pressure Monitoring Equipment Testing 0 C T 17 2016 This page should be used to document testing and servicing of vacuum and pressure ' r of this form must be included with the Monitoring System Certification Form, e v' o the tank system owner/operator. The owner/operator must submit a copy of the Monitoring Syste is n orm 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: FUEL OIL RETURN LINE S-1 Sensor Functionality Test Result: ® Pass; ❑ Fail Interstitial Communication Test Result: ❑ Pass; ❑ Fail S-2 Component(s)Monitored by this Sensor: FUEL OIL SUPPLY LINE Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail S-3 Component(s)Monitored by this Sensor: VENT LINE Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail S-4 Component(s)Monitored by this Sensor: REMOTE FILL LINE 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 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: LODI MEMORIAL HOSPITAL-LODI 10-6-16 SITE TESTING, THERE IS NO I QVV POR P Al I SENSOR ACTIVE AND WORKING 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