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r UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) VI . INVENTORY OF EQUIPMENT CERTIFIED A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. Make of Monitoring System Control Panel adel of Monitoring System Control Panel Software Version Installed M VEEDER ROOT T L S - 3 5 0 PLUS ! 334 . 00 Check the appropriate boxes to indicate specific equipment ins ected/serviced. Monitoring Device Used,_L Device Model # Monitoring Device Used Device Model # TANK ID : 87 OCT - WEST TANK ID : 87 OCT - CENTER (By tank number, stored product, e (By tank number, stored product, etc. • In-Tank Gauging (SW Tank) M A G 1 9 In-Tank Gauging (SW Tank) M A G 1 Nx Annular Space or Vault Sensor 4 0 9 0 Annular Space or Vault Sensor 4 0 9 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑x Electronic LLD P L L D - 8 4 8 4 ❑ Electronic LLD SYPHON ONLY ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) xN Sump Sensor 2 0 8 xN Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) Nx Sump Sensor 3 2 3 0 Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) N Sump Sensor 2 0 8 ❑x Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) Nx Sump Sensor 2 0 8 ❑p Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : 87 OCT - EAST TANK ID : 4 - 91 OCTANE (By tank number, stored product, etcj (By tank number, stored product, etc. Nx In-Tank Gauging (SW Tank) M A G 1 ❑x In-Tank Gauging (SW Tank) M A G 1 N Annular Space or Vault Sensor 4 0 9 [E Annular Space or Vault Sensor 4 0 9 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD 0 Electronic LLD SHARED LINE 0 Electronic LLD P L L D - 8 4 8 4 ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) x❑ Sump Sensor 3 2 3 xN Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) Nx Sump Sensor 3 2 3 ❑x Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) Z Sump Sensor 3 2 3 ❑x Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) p Sump Sensor 3 2 3 p Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) ID = Identification, SW = Single-Waded, VPH = VacuumlPressureMydrostatic, LLD = Line Leak Detector