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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) 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 Model of Monitoring System Control Panel Software Version Installed VEEDER ROOT SYMPLICITY 329 . 01 Check the appropriate boxes to indicatespecific equipment ins ected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : 87 TANK ID : 91 (By tank number, stored product, e (By tank number, stored product, etc. ❑x In-Tank Gauging (SW Tank) MAG 1 0 In-Tank Gauging (SW Tank) MAG 1 ❑x Annular Space or Vault Sensor 302 9 Annular Space or Vault Sensor 302 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑x Electronic LLD PLLD Z Electronic LLD PLLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 352x❑ Sump Sensor 352 ❑ 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 ❑ VPN Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPN 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 # Monitoring Device Used Device Model # TANK ID : DSL TANK ID : (By tank number, stored product, etcj (By tank number, stored product, etc. ❑x In-Tank Gauging (SW Tank) MAG 1 ❑ In-Tank Gauging (SW Tank) 0 Annular Space or Vault Sensor 302 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD (] Electronic LLD PLLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 352 ❑ 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-Walled, VPH = Vacuum/Pressure/Hydrostatic, LLD = Line Leak Detector I