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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) PLLD ❑ Electronic LLD FA V1. INVENTORY OF EQUIPMENT CERTIFIED )] Sump Sensor eparate Monitoring System Certification Form must be prepared for each monitoring system contro7panel. Make of Monitoring System Control Panel VEEDER ROOT Model of Monitoring System Control Panel Software Version Installed TLS 350 334.01 Check the appropriate boxes to indicates ecific equipment ins ected/serviced. Fill Piping Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: (By tank number, stored product, e 87_1 TANK ID: (By tank number, stored product, etc. 87_2 0 In Tank Gauging (SW Tank) MAG -1 ❑x In -Tank Gauging (SW Tank) MAG -1 0 Annular Space or Vault Sensor 407 ❑x Annular Space or Vault Sensor 407 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD El Electronic LLD PLLD Electronic LLD PLLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) Sump Sensor 352 ❑x Sump Sensor 352 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) 9 Sump Sensor 208 Q Sump Sensor 208 ❑ 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) Monitoring Device Used Device Model # Monitorinq Device Used Device Model # TANK ID: (By tank number, stored product, e 91 TANK ID: (By tank number, stored product, etc - N In -Tank Gauging (SW Tank) MAG -1 ❑ In -Tank Gauging (SW Tank) ❑x Annular Space or Vault Sensor 407 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD N Electronic LLD PLLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) )] Sump Sensor 352 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) 9 Sump Sensor 208 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor I ❑ 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 -Walled, VPH = VacuumlPressurelHydrostafic, LLD = Line Leak Detector