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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page a of s) Monitoring Device Used Device Model # Monitoring Device Used Device Model # VENT / TRANSITION SUMP I0: _ VENT t TRANSITION SUMP ID: ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor ❑ VPH Sensor UDC ID : 1 /2 UDC ID : 3/4 ❑ Electronic Sensor ❑ Electronic Sensor 0 Mechanical Device Float and Chain 0 Mechanical Device Float and Chain ❑ VPH Sensor ❑ VPH Sensor UDC ID : 5/6 UDC ID: 7/8 ' ❑ Electronic Sensor ❑ Electronic Sensor 0 Mechanical Device Float and Chain 0 Mechanical Device Float and Chain ❑ VPH Sensor ❑ VPH Sensor UDC ID : 9/ 10 UDC ID : 11 /12 ❑ Electronic Sensor ❑ Electronic Sensor 0 Mechanical Device Float and Chain 0 Mechanical Device Float and Chain ❑ VPH Sensor ❑ VPH Sensor UDC ID: 4 UDC ID: ❑ Electronic Sensor ❑ Electronic Sensor ❑ Mechanical Device ❑ Mechanical Device ❑ VPH Sensor ❑ VPH Sensor Other Monitored Component ID: Other Monitored Component ID: ❑ Other (Specify in section V11.) ❑ Other (Specify in section Vll.) Other Monitored Component ID: Other Monitored Component ID: ❑ Other (Specify in section V11.) ther (Specify in section VIL) Other Monitored Component ID: Other Monitored Component ID: ❑ Other (Specify in section V11.) I ❑ Other (specify in section Vll.) Include information for every underground storage tank component monitored by this monitoring system control panel. If the monitoring system control panel monitors more components than this form accommodates, addltfonal conies of these pages maybe attached, m _ VII . COMMENTS Use this section to provide additional comments about the inventory of the equipment certified. Estops - Tested & Passed . Shear Valves - Tested & Passed . [D = Identification, VPH = Vacuum Pressum#+Arostafic, UDC = Under-0ispenser Containment