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UNDERGROUND ST GE TANK MONITORING SYSTEM CERTIFI TION FORM (Page 2 of 6) VI . INVENTORY OF EQ JltfiLENT CERTIFIED A separate Monitoring System Certification Form must be rdpared for each monitoring system control pane/ Make of Monitoring System Control Panel Model of Monitoring Sy tem Control Panel Software Version Installed VEEDER ROOT 0 1L$ 350 Check the appropriate boxes to indicate specific equipment ins ect d/serviced. Monitoring Device Used Device Model # TANK IDoriitorin Device Used Device Model # : (By tank number, stored product, etc. JET- 1 TAN ID: JET-2 (By I ink number, stored product, etc. 0 In-Tank Gauging (SW Tank) MAG- 1 ❑x Ir -Tank Gauging (SW Tank) MAG II Annular Space or Vault Sensor 420 0 A inular Space or Vault Sensor 409 ❑ VPH Sensor El V H ' Sensor Product Piping Pro uc Piping ❑x Mechanical LLD FXIV D [x] Mechanical LLD FXIV D ❑ Electronic LLD ❑ E ecfronic LLD ❑ VPH Sensor (Piping) ❑ V H Sensor (Piping) ❑x Sump Sensor 208 ❑x S imp Sensor 208 ❑ VPH Sensor (Sump) ❑ WH (Sump) Fill Piping Fill F 'ping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ V H Sensor (Sump) Vent Piping Vent !ping ❑ VPH Sensor (Piping) ❑ VF IH Sensor ( Piping) ❑ Sump Sensor ❑ SL mo Sensor ❑ VPH Sensor (Sump) ❑ V H Sensor (Sump) Vapor Recovery Piping Vapo a Recovery Piping ❑ VPH Sensor (Piping) ❑ VF1H Sensor (Piping) ❑ Sump Sensor ❑ St mp Sensor ❑ VPH Sensor (Sump) ❑ V H Sensor (Sump) Monitoring Device Used Device Model # M iq Device Used Device Model # TANK ID : JET TAN ID: 8 tank number, stored roduct, etc. B to k number, stored product, efc. ❑x In-Tank Gauging (SW Tank) MAG- 1 ❑ In-rank Gauging (SW Tank) ❑x Annular Space or Vault Sensor 409 ❑ An lular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product iping 0 Mechanical LLD LD 3000 H F ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VP H Sensor (Piping) Z Sump Sensor 208 ❑ Su np ;Sensor ❑ VPH Sensor (Sump) ❑ VP Sensor (Sump) Fill Piping Fill Pi ing ❑ VPH Sensor (Piping) ❑ VP Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPI I Sensor (Sump) Vent Piping Vent Fipi g ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPN Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor ( Piping) ❑ VPI I Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor [I VPH Sensor (Sump) ❑ VP IS (Sump) ID = Identification, SW = Single-Walled, VPH = VacuumlPressureMydrostatic, LLD = Line Leak De actor