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UNDERGROUND STORAGE TANK <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 monitorin s stem control panel. <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed <br /> Veeder Root TLS-350 333.00 <br /> Check the appropriate boxes to indicatespecific equipment inspected/serviced. <br /> Monitoring Device Used I Device Model # Monitoring Device Used I Device Model # <br /> Tank ID: T1 Supreme Gasoline- Premium Tank ID: T3 Regular 1 Gasoline- Regular <br /> (By tank number, stored product, etc.) (By tank number, stored product, etc.) <br /> W In-tank Gauging (SW Tank) Mag W In-tank Gauging(SW Tank) Mag <br /> W Annular Space or Vault Sensor 794390-409 r Annular Space or Vault Sensor 794390-409 <br /> r VPH Sensor r VPH Sensor <br /> Product Piping Product Piping <br /> r Mechanical LLD f Mechanical LLD <br /> W Electronic LLD 848480-001 W Electronic LLD 848480-001 <br /> r VPH Sensor(Piping) r— Sensor(Piping) <br /> W Sump Sensor 794380-208 W Sump Sensor 794380-208 <br /> I— VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> r VPH Sensor(Piping) r VPH Sensor(Piping) <br /> W Sump Sensor 794380-208 rv-1 Sump Sensor 794380-208 <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 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 /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> Tank ID: T2 Regular 2 Gasoline-Regular Tank ID: <br /> (By tank number, stored product, etc.) (By tank number, stored product, etc.) <br /> (1 In-tank Gauging (SW Tank) Mag r In-tank Gauging (SW Tank) <br /> C✓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 /> r Mechanical LLD r Mechanical LLD <br /> W Electronic LLD 848480-001 r Electronic LLD <br /> I—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 /> I- VPH Sensor(Piping) r VPH Sensor(Piping) <br /> r Sump Sensor 794380-208 r Sump Sensor <br /> F VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> I-VPH Sensor(Piping) r VPH Sensor(Piping) <br /> F 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 /> (�VPH Sensor(Sump) r VPH Sensor(Sump) <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council <br />