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Monitoring System Certification Form:Addendum for Vacuum/Pressure Interstitial Sensors LG 163-1,Enc.II 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:veederroot Model:001 System Type:F Pressure F*' Vacuum Sensor ID sl Component(s)Monitored by this Sensor: dsl roduct Sensor Functionality Test Result: Pass ❑Fail Interstitial Communication Test Result: �i Pass ...:Fail s2 Component(s)Monitored by this Sensor: dsl 2 product Sensor Functionality Test Result:FOO.Pass ❑Fail Interstitial Communication Test Result: Pass F Fail s3 Component(s)Monitored by this Sensor: vents Sensor Functionality Test Result:F Pass ❑Fail Interstitial Communication Test Result: Y!:Pass U Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass ❑Fail Interstitial Communication Test Result: _.!Pass U Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass ❑Fail Interstitial Communication Test Result: ... Pass LJ Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass ❑Fail Interstitial Communication Test Result:0 Pass _Fail Component(s)Monitored by this rSSensor: ESensor Functionality Test Result:E.Pass ❑Fail Interstitial Communication Test Result: ...'Pass L1 Fail Component(s)Monitored by this�Sensor: Sensor Functionality Test Result:L.A Pass ❑Fail Interstitial Communication Test Result: .._:Pass I Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass ❑Fail Interstitial Communication Test Result: ... Pass _J Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:❑Pass ❑Fail Interstitial Communication Test Result: .-.:Pass 0 Fail How was interstitial communication verified? * Leak Introduced at Far End of Interstitial Space' n Gau e F Visual Inspection Other Describe in Sec.J,below Vacuum was restored to operating levels in all interstitial spaces: F Yes F No (If no, describe in Sec. J, below) J.Comments(500 characters max.use additional sheets if needed): Page 4 of 4 1 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. WO: 2335977