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B. Inventory of Equipment Tested/Certified: Tank ID: 87A ®In -Tank Gauging Probe. Model: Mag 1 ®Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: NONE ® Mechanical Line Leak Detector. Model: Red Jacket ❑ Electronic Line Leak Detector. Model: NONE ®Tank Overfill / High -Level Sensor. Model: Drop Tube ® Fillspill buckets tested ❑Pass ❑Fail Tank ID: 91 ®In -Tank Gauging Probe. Model: Mag 1 ®Annular Space or Vault Sensor. Model: 794390-409 ®Piping Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: NONE ® Mechanical Line Leak Detector. Model: FE Petro ❑ Electronic Line Leak Detector. Model: NONE ®Tank Overfill / High -Level Sensor. Model: Drop Tube M FIIIsDIII buckets tested MPass ❑Fail Vapor Condensate Sump: ®Dry ❑Water ❑Pr ® Sensor(s). Model: 7943 Vapor Pot Sensor(s). Model: 7943 Tank ID: 87B ®In -Tank Gauging Probe. ®Annular Space or Vault Sensor. ® Piping Sump Sensor(s). El Fill Sump Sensor(s). ❑ Mechanical Line Leak Detector. ❑ Electronic Line Leak Detector. ®Tank Overfill / High -Level Sensor R Fillsoill buckets tested RPa: Model: Mag 1 Model: 794390-409 Model: 794380-208 Model: NONE Model: Shared Model: NONE Model: Drop Tube s nFail Tank ID: ❑In -Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump Sensor(s). Model: [:]Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑Tank Overfill,/ High -Level Sensor. Model: Dispenser ID: 1 &2 ® Sump: ®Dry ❑Water ❑Product Dispenser ID: 3&4 Z Sump: ®Di ® Dispenser Containment Model: Float and Chain ® Dispenser' Containment ®Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) ®Dispenser Containment Float(s) and Chain(s). ®Dispenser Containment Floats) Dispenser ID: 5&6 ® Sump: ®Dry ❑Water ❑Product Dispenser ID: 7&8 ® Sump: ®Di ® Dispenser Containment Model: Float and Chain ® Dispenser Containment ® Shear Valves) (Functional test) ® Shear Valve(s) (Functional test) 15 I Dispenser Containment Float(s) and Chain(s). ® Dispenser Containment Float(s), C. Certification - I certify that the equipment identified in this manufacturers' guidelines. Attached to this Certification is information information is correct and a Plot Plan showing the layout of monitoring reports, I have also attached a copy of the report; (check all that apply): i Signature of Technician: Date: Certification: ICC UST Technician # 8152115 -UT Veeder Root # 836877 Level 4 ISD ❑Product : 794380-208 roduct nd Chain