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Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors 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. J. Comments: -8-30-18 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. R 01/26/06 UN -036A - 1/1 www.umdocs.org cv Model: TLS- 350 System Type: ❑ Pressure; ® Vacuum Manufacturer: VEEDER ROOT Sensor ID- mmComponent(s) Monitored by this Sensor: Sensor Functionality Test Result: ®Pass; 87 El PRODUCT LINE Fail Interstitial Communication Test Result: ®Pass; El Fail S-1 S-2 Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ® Pass; VAPOR ❑ Fail RETURN LINE Interstitial Communication Test Result: ® Pass; ❑ Fail S-3 Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ® Pass; 91 ❑ PRODUCT LINE Fail Interstitial Communication Test Result: ® Pass; ❑ Fail S-4 Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ® Pass; 87191 VENT LINES ❑ Fail Interstitial Communication Test Result: ® Pass; ❑ Fail S-5 Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ® Pass; DIESEL ❑ Fail PRODUCT LINE Interstitial Communication Test Result: ® Pass; ❑ Fail S-6 Component(s) Monitored by this Sensor: Sensor Functionality Test Result: ® Pass; DIESEL ❑ Fail VENT LINE 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 ❑ Leak interstitial communication verified? Introduced at Far End of Interstitial Space;' ❑ Gauge; ® Visual Inspection; ❑ Other (Describe in See. J, below) Was vacuum/pressure restored to operating levels in all interstitial spaces? ® Yes ❑ No (If no, describe in See. J, below) J. Comments: -8-30-18 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. R 01/26/06 UN -036A - 1/1 www.umdocs.org cv