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UNDERGROUNDSTORAGETANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of s) 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 Veeder Root Model of Monitoring System Control Panel TLS-350 Software Version Installed Check the qppropriate boxes to indicate specific equipment inspected/serviced. Monitorin Device Used Device Model # Monitoring Device Used Device Model # TANK ID: (By tank number, stored product, etc.) 87 TANK ID: (By tank number, stored product, etc. 91 ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) ❑x Annular Space or vault Sensor 0794380-409 ❑x Annular Space or vault Sensor 0794380-409 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping Z Mechanical LLD VMI 99LD-2000 ❑x Mechanical LLD Fe-Petro ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑p Sump Sensor 0794380-208 ❑D Sump Sensor 0794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Lmonitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: B tank number, storedproduct, etc. ❑ In-Tank Gauging (SW Tank) Diesel TANK ID: 8 tank number, storedproduct, etc. ❑ In-Tank Gauging (SW Tank) 0 Annular Space or vault Sensor 0794380-409 ❑ Annular Space or vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑x Mechanical LLD VMI 99LD-2000 ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) x❑ Sump Sensor 0794380-208 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) ID= Identification, SW = Single -Waled, VPH = VacuumlPressureHydrostafic, LLD = Line Leak Detector