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i <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) <br /> VI. INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System Certflication Form must be prepared for each monitoring system control panel. <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed <br /> Veeder Root TLS-350R 330. 03 <br /> Check the appropriate boxes to Indicates ecitic a ui ment Inspected/serviced. <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # IN liiiiiiiin <br /> Tank ID: T1 : 87 Master Tank IDs T2 : 87 Slave <br /> (AV tank number, stored girmoduct, etcJ (By tank number, storedrods etc. <br /> ❑ In-tank Gauging (SW Tank) ❑ In-tank Gauging (SW Tank) <br /> ® Annular Space or vault Sensor 794390409 ® Annular Space or Vault Sensor 794390= 409 <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> ❑ Mechanical LLD ❑ Mechanical LLD <br /> ® Electronic LLD 8484 ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor 794380-323 ® Sump sensor 794380-323 <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump sensor 794380-208 ® Sump Sensor 794380-323 <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Vent Piping Vent Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> Tank ID: T3 : 91 Tank ID : <br /> (By tank number, stored product, etc. B tank number stored roduct etc. <br /> ❑ In-tank Gauging (SW Tank) ❑ in-tank Gauging (SW Tank) <br /> ® Annular Space or Vault Sensor 794390409 ❑ Annular Space or Vault Sensor <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> ® Mechanical LLD VMI 99LD-2000 ❑ Mechanical LLD <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor 794380-323 ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Fill Piping Fili Pi in <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor 794380-323 ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Vent Piping Vent Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> In o Wonfifiralim gw= .gimw uraw VPH n Vara n uwPraam mwi4vrfmaMnr. I I n o t ina leak riafarinr <br />