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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) VI . INVENTORY OF EQUIPMENT CERTIFIED A separate Monitoring System Certification Form must be prepared for each monitoring system control panel, Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed Veeder Root Gilbarco EMC 333 . 03 Check the appropriate boxes to indicate specific equipment in ected/serviced. Monitoring Device Used Device Model # Monitorino Device Used Device Model # TANK ID : 1 Regular TANK ID : Super B tank number, stored product, etc.) (By tank number, stored product, etc. ® In-Tank Gauging (SW Tank) 846390-108 la In-Tank Gauging (SW Tank) 846390- 108 ® Annular Space or Vault Sensor 794390=420 m Annular Space or Vault Sensor 794390-420 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping 0 Mechanical LLD RJ 116-056-5 m Mechanical LLD RJ 116-056-5 ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor 794380=208 ® Sump Sensor 794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor 794380-208 ® Sump Sensor 794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor i ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # Monitorin Device Used Device Model # TANK ID : TANK ID : fByy tank number, stored roduct, etc3 Diesel (By tank number, stored product, etc. 21 In-Tank Gauging (SW Tank) 847390-107 ❑ Ill Gauging (SW Tank) ® Annular Space or Vault Sensor 794390420 ❑ Annular Space or Vault Sensor E) VPN Sensor [I VPH Sensor Product Piping Product Piping ® Mechanical LLD VMI LD2000 ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor 794380-208 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor 794380-208 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) ID = Identification, SW = Single-Walled, VPH = VaaiunVPressueMydrostatic, LLD = Line Leak Detector