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UNDERGROUNDSTORAGETANK MONITORING SYSTEM CERTIFICATION FORM (Page z 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 PanelModel VEEDER ROOT of Monitoring System Control Panel TLS -350 Software Version Installed 333.03 Check the appropriate boxes to indicatespecific equipment inspected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: (By tank number, stored product, etc.) 87 OCTANE TANK ID: (By tank number, stored product, etc. 91 OCTANE ❑x In -Tank Gauging (SW Tank) M A G 1 9 In -Tank Gauging (SW Tank) M A G 1 ❑x Annular Space or Vault Sensor 4 0 9 0 Annular Space or Vault Sensor 4 0 9 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping 0 Mechanical LLD 99 LD 2000 ❑X Mechanical LLD 99 LD 2000 ❑ Electronic LLD ❑ Electronic LLD _ ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 2 0 8 E Sump Sensor 2 0 8 ❑ 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) p Sump Sensor 2 0 8 p Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) p Sump Sensor 2 0 8 p Sump sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: (By tank number, stored product, etc.) DIESEL TANK ID: (By tank number, stored product, etc. WASTE OIL 0 In -Tank Gauging (SW Tank) M A G 1 ❑ In -Tank Gauging (SW Tank) _ x❑ Annular Space or Vault Sensor 4. 0 9 Z Annular Space or Vault Sensor 4 0 3 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping 0 Mechanical LLD 99 LD 2000 ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 2 0 8 ❑ 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) 0 Sump Sensor 2 0 8 ❑ 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 = VacuumlPressure/Hydrostatic, LLD = Line Leak Detector