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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM(Pae 2 of 6) <br /> VI. INVENTORY OF EQUIPMENT CERTIFIED j <br /> A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel I Software Version Installed <br /> Veeder Root I TLS-350 1328.03 <br /> Check the appropriate boxes to indicate specific equipment in <br /> Monitoring Device Used Device Model# Monitoring Device Used Device Model# <br /> TANK ID:01 Reg TANK ID: 02 Plus <br /> (By tank number, stored product,etc..1 (By tank number,stored product etc.) <br /> ❑In-Tank Gauging(SW Tank) I ❑in-Tank Gauging(SW Tank) <br /> m Annular Space or Vault Sensor VR 794380-301 0 Annular Space or Vault Sensor VR 794380-301 <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> ❑Mechanical LLD ❑Mechanical LLD <br /> (a Electronic LLD VR 8484 0 Electronic LLD VR 8484 <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> Sump Sensor (A-STP Sump)VR 794380-352 0 Sump Sensor (A-STP Sump)VR 794380-352 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Fill Piping I Fill Piping I <br /> ❑VPH Sensor(Piping) I ❑VPH Sensor(Piping) <br /> 0 Sump Sensor VR 794380-208 m Sump Sensor VR 794380-208 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping I <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Monitoring Device Used Device Model# Monitoring Device Used Device Model# <br /> TANK ID: 03 Prem TANK ID:04 Diesel <br /> 1By tank number,stored product,etc.) tBy tank number,stored product,etc.) <br /> ❑In-Tank Gauging(SW Tank) 1 ❑In-Tank Gauging(SW Tank) <br /> ®Annular Space or Vault Sensor VR 794380-301 0 Annular Space or Vault Sensor VR 794380-301 <br /> ❑VPH Sensor ❑VPH Sensor <br /> I Product Piping Product Piping <br /> ❑Mechanical LLD ❑Mechanical LLD <br /> JZ Electronic LLD VR 8484 0 Electronic LLD VR 8484 <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> 0 Sump Sensor (A-STP Sump)VR 794380-352 0 Sump Sensor VR 794380-208 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> 0 Sump Sensor VR 794380-208 m Sump Sensor VR 794380-208 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> E]VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> ID=idenlfication,SW=Single-Waled,VPH=VactwWresweHydrostei6c,LLD=Line Leak Detector <br />