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'PRECEIVED <br /> Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors <br /> I. Results of Vacuum/Pressure Monitoring Equipment Testing OCT 13 2016 <br /> This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of this <br /> form must be included with the Monitoring System Certification Form, which must be N%R0t4ky LTH <br /> owner/operator. The owner/operator must submit a copy of the Monitoring System CertificatiLF cal <br /> agency regulating UST systems within 30 days of test date. <br /> Manufacturer:VEEDER ROOT Model:TLS-350 System Type: ❑Pressure; ®Vacuum <br /> , <br /> Sensor ID - � -,_�` �„ ���M��.Mill,�— <br /> Component(s)Monitored by this Sensor: FUEL OIL RETURN LINE <br /> S-1 <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> S -2 Component(s)Monitored by this Sensor: FUEL OIL SUPPLY LINE <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> S -3 Component(s)Monitored by this Sensor: VENT LINE <br /> Sensor Functionality Test Result: ®Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Component(s)Monitored by this Sensor: REMOTE FILL LINE <br /> S-4 <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 /> Component(s)Monitored by this Sensor: <br /> Sensor Functionality Test Result: ❑Pass; ❑ Fail Interstitial Communication Test Result: ❑Pass; ❑ Fail <br /> Components)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, <br /> 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-LODI 10-6-16 <br /> SITE IS NOT EQUIPPED FOR COMMUNICATION TESTING, THE SUMPS ARE NOT BUILT FOR COMMUNICATION <br /> TESTING, THERE IS NO LOW PORT ON ANY SUMP.ALL SENSOR ACTIVE AND WORKING <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.unidoes.org Rev.01/26/06 <br />