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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page z of s) <br /> VI. INVENTORY OF EQUIPMENT CERTIFIED <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 Software Version Installed <br /> Veeder Root Gilbarco EMC 334.00 <br /> Check the appropriate boxes to indicatespecific equipment inspected/serviced. <br /> Monitoring Device Used Device Model# Monitoring Device Used Device Model# <br /> TANK ID: 87 Gasoline TANK ID: 89 Gasoline <br /> (By tank number,stored product,etc.) (By tank number,stored product,etc. <br /> ❑In-Tank Gauging(SW Tank) ❑In-Tank Gauging(SW Tank) <br /> Z Annular Space or vault Sensor 0794390-409 ❑x Annular Space or Vault Sensor 0794390-409 <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> ❑x Mechanical LLD Red Jacket FX x❑Mechanical LLD VMI 99LD-2000 <br /> ❑Electronic LLD ❑Electronic LLD <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑x Sump Sensor 0794380-208 ❑x Sump sensor 0794380-208 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <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 <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: 91 Gasoline TANK ID: <br /> (By tank number,stored product,etc.) (By tank number,stored product,etc. <br /> ❑In-Tank Gauging(SW Tank) ❑In-Tank Gauging(SW Tank) <br /> ❑x Annular Space or Vault Sensor 0794390-409 ❑Annular Space or Vault Sensor <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> ❑x Mechanical LLD VMI 99LD-2000 ❑Mechanical LLD <br /> ❑Electronic LLD ❑Electronic LLD <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> Z Sump Sensor 0794380-208 ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vent Piping Vent Piping I I AI I`1 P,+T"-' <br /> ❑VPH Sensor(Piping) El VPH Sensor(Piping) :T <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) ILE VPH Sensor(Sump) <br /> ID=Identification,SW=Single-Walled,VPH=VacuumlPressurell-lydrostafic,LLD=Line Leak Detector <br />