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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 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 PanelModel of Monitoring System Control Panel Software Version Installed <br /> VEEDER ROOT TLS - 350 328 . 03 <br /> Check the appropriate boxes to indicate specific equipment inspected/serviced <br /> Monitoring Device Used Device Model# Monitorin Device Used T Device Model# <br /> TANK ID: 87 OCTANE TANK ID: 91 OCTANE <br /> 8 tank number,storedproduct,etc. 8 tank number,storedproduct,etc. <br /> X In-Tank Gauging(SW Tank) M A G 1 ❑X In-Tank Gauging(SW Tank) M A G 1 <br /> Z Annular Space or vault Sensor 4 2 0 ❑x Annular Space or vault Sensor SHARED W/ 87 OCT <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> ❑x Mechanical LLD FE - STP - MLD Z Mechanical LLD FE - STP - MLD <br /> ❑Electronic LLD ❑Electronic LLD <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑x Sump Sensor 2 0 8 ❑x Sump Sensor 2 0 8 <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 /> ❑x Sump Sensor 2 0 8x❑Sump sensor 2 0 8 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑x Sump Sensor 2 0 8 ❑x Sump Sensor 2 0 8 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Monitoring Device Used Device Model# Monitoring Device Used Device Model# <br /> TANK ID: DIESEL # 2 TANK ID: <br /> (By tank number,stored product,e (By tank number,stored product,etc. <br /> Z In-Tank Gauging(SW Tank) M A G 1 ❑In-Tank Gauging(SW Tank) <br /> ❑x Annular Space or Vault Sensor 4 2 0 ❑Annular Space or Vault Sensor <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> ❑x Mechanical LLD V M I - 99 LD 2000 ❑Mechanical LLD <br /> ❑Electronic LLD ❑Electronic LLD <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑x Sump Sensor 2 0 8 ❑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 <br /> ❑VPH Sensor(Piping) ElVPH Sensor(Piping) <br /> 9 Sump Sensor 2 0 8 ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> [:1 VPH Sensor(Piping) ❑VPH Sensor(Piping) R I v rAL <br /> 'rJEA1 IH- <br /> 0 Sump Sensor ❑Sump Sensor DFR8 RTP,;;F <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> ID=Identification,SW=Single-Walled,VPH=VacuumlPressureMydrostatic,LLD=Line Leak Detector <br />