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RECEIVED BY EHD: 7/27/2021 Monitoring System Certification Form:Addendum for Vacuum/Pressure Interstitial Sensors (received via Crompco Vault Portal) 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:r—Pressure F70 Vacuum Sensor ID sl Component(s)Monitored by this Sensor: ds] roduct Sensor Functionality Test Result:F Pass I.]Fail Interstitial Communication Test Result: '�j Pass . :Fail sZ Component(s)Monitored by this Sensor: dsl 2 product Sensor Functionality Test Result:I'0 Pass I.J Fail Interstitial Communication Test Result: � Pass _S Fail Component(s)Monitored by this Sensor: vents s3 Sensor Functionality Test Result:�Pass E—J Fail Interstitial Communication Test Result:IWO Pass I_1 Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:I :Pass I. :Fail Interstitial Communication Test Result: :Pass 'Fail Component(s)Monitored by this Sensor: r Sensor Functionality Test Result:I :Pass I :Fail Interstitial Communication Test Result: :Pass .S Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:I :Pass F-1 Fail Interstitial Communication Test Result: _.J Pass _J Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:F.Pass F.Fail Interstitial Communication Test Result: _ Pass 7 Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:I :Pass F J Fail Interstitial Communication Test Result: - S Pass 'Fail Component(s)Monitored by this Sensor: Sensor Functionality Test Result:F.Pass I :Fail Interstitial Communication Test Result: :Pass 'Fail Component(s)Monitored by this Sensor: � Sensor Functionality Test Result:F—Pass I. :Fail Interstitial Communication Test Result: _S Pass _1 Fail ow was interstitial communication verified? '/'Leak Introduced at Far End of Interstitial Space' r Gauge F Visual Inspection F Other Describe in Sec.J,below Vacuum was restored to operating levels in all interstitial spaces: F Yes F—I 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. W0: 2335977