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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 monitoring system control panel. <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed <br /> Veeder Root TLS-350R 1333.03 <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: T4 RUL Gasoline-Regular Tank ID: T5 MUL Gasoline-Midgrade <br /> (By tank number, stored product, etc.) (By tank number, stored product, etc.) <br /> P-1 In-tank Gauging(SW Tank) MAG r In-tank Gauging(SW Tank) MAG <br /> W Annular Space or Vault Sensor 794380-302 Annular Space or Vault Sensor 794380-302 <br /> r VPH Sensor r VPH Sensor <br /> Product Piping Product Piping <br /> Mechanical LLD LD-2000 W Mechanical LLD LD-2000 <br /> I` Electronic LLD r Electronic LLD <br /> r VPH Sensor(Piping) r VPH Sensor(Piping) <br /> r Sump Sensor 794380-352 W Sump Sensor 794380-352 <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> F_ VPH Sensor(Piping) F_ VPH Sensor(Piping) <br /> I✓Sump Sensor 794380-208 r Sump Sensor 794380-208 <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> r VPH Sensor(Piping) I— VPH Sensor(Piping) <br /> f Sump Sensor I—Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> r VPH Sensor(Piping) I— VPH Sensor(Piping) <br /> r Sump Sensor r Sump Sensor <br /> r VPH Sensor(Sump) I—VPH Sensor(Sump) <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> Tank ID: T6 PUL Gasoline- Premium Tank ID: <br /> (By tank number, stored product, etc.) (By tank number, stored product, etc.) <br /> WO In-tank Gauging (SW Tank) MAG r In-tank Gauging(SW Tank) <br /> W Annular Space or Vault Sensor 794380-302 I Annular Space or Vault Sensor <br /> r VPH Sensor r VPH Sensor <br /> Product Piping Product Piping <br /> C✓ Mechanical LLD LD-2000 I— Mechanical LLD <br /> F Electronic LLD r Electronic LLD <br /> r VPH Sensor(Piping) r VPH Sensor(Piping) <br /> rv-1 Sump Sensor 794380-352 1 Sump Sensor <br /> I— VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> F_ VPH Sensor(Piping) r VPH Sensor(Piping) <br /> r Sump Sensor 794380-208 r Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> r VPH Sensor(Piping) f— VPH Sensor(Piping) <br /> I—Sump Sensor r— Sensor <br /> I— VPH Sensor(Sump) f—VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> I— VPH Sensor(Piping) r VPH Sensor(Piping) <br /> r—Sump Sensor I Sump Sensor <br /> F VPH Sensor(Sump) r VPH Sensor(Sump) <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council <br />