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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) <br /> VI. INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System Certification 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 71 TLS-350R 333 . 03 <br /> Check the appropriate boxes to Indicate s eciflc equipment Ins cted(serviced. <br /> Monitoring Device Used Device Model # Monitorina Device Used Device Model # <br /> Tank ID : T1 : 87 Master Tank ID : T2 : 87 Slave <br /> (By tank number, stored product, etc.) fBy tank number, stored product, etc. <br /> ❑ In•tank Gauging (SW Tank) ❑ In-tank Gauging (SW Tank) <br /> ® Annular Space or Vault Sensor 794390409 ® Annular Space or Vault Sensor 794390409 <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 # MonitoringDevice Used Device Model # <br /> Tank ID: T3 : 91 Tank ID: <br /> (By tank number, stored product, etc.) (Bv tank number, stored product, etc. <br /> ❑ In-tank Gauging (SW Tank) ❑ In-tank Gauging (SW Tank) <br /> ® Annular space or Vault sensor 794390-409 ❑ Annular space or vault sensor <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Ploinal <br /> ® Mechanical LLD VMI 991.D-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) ❑ VPN Sensor (Sump) <br /> Fill Piping Fill Piping <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 /> Ina 1dPntifistxHnn SW a R1nnla v =1M VPH a Vara a urdPn+aam imJHv ir. 1 i n = I Ina task riahrinr <br />