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RECEIVF <br /> UNDERGROUND STORAGE TANK JUL 2 X070 <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) <br /> VI. INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System Certification Form must be prepared for each monitori 9idM!'4ck {lel, _ <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel Softwfp <br /> Ind <br /> Veeder Root TLS-350 1333.05-* <br /> Check the appropriate boxes to indicatespecific equipment inspected/serviced. <br /> Monitoring Device Used Device Model# Monitoring Device Used Device Model # <br /> Tank ID: T-1 Gasoline-Regular Tank ID: <br /> (By tank number, stored product, etc.) (By tank number, stored product, etc.) <br /> 57 In-tank Gauging (SW Tank) MAG I—In-tank Gauging (SW Tank) <br /> I7 Annular Space or Vault Sensor 794390-407 r Annular Space or Vault Sensor <br /> r VPH Sensor r VPH Sensor <br /> Product Piping Product Piping <br /> Mechanical LLD FX1V f Mechanical LLD <br /> F Electronic LLD r— Electronic LLD <br /> F VPH Sensor(Piping) I— VPH Sensor(Piping) <br /> W Sump Sensor 794380-208 I Sump Sensor <br /> r VPH Sensor(Sump) VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> F VPH Sensor(Piping) I—VPH Sensor(Piping) <br /> I Sump Sensor I Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> r VPH Sensor(Piping) r_VPH Sensor(Piping) <br /> I- Sump Sensor I— Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> I- VPH Sensor(Piping) r VPH Sensor(Piping) <br /> r Sump Sensor r Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Monitoring Device Used Device Model# Monitoring Device Used Device Model # <br /> Tank ID: T-2 Gasoline- Premium Tank ID: <br /> (By tank number, stored product, etc.) (By tank number, stored product, etc.) <br /> W In-tank Gauging (SW Tank) MAG r In-tank Gauging (SW Tank) <br /> W Annular Space or Vault Sensor 794390-409 r Annular Space or Vault Sensor <br /> r VPH Sensor r VPH Sensor <br /> Product Piping Product Piping <br /> W Mechanical LLD FX1V r Mechanical LLD <br /> F Electronic LLD r Electronic LLD <br /> r VPH Sensor(Piping) r VPH Sensor(Piping) <br /> W Sump Sensor 794380-208 r Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> r VPH Sensor(Piping) r VPH Sensor(Piping) <br /> r Sump Sensor r Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> I- VPH Sensor(Piping) r VPH Sensor(Piping) <br /> r Sump Sensor r Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> r VPH Sensor(Piping) r VPH Sensor(Piping) <br /> r Sump Sensor r Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council <br />