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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 /> GILBARCO EMC 16 . 02 <br /> Check the appropriate boxes to indicate specific equipment inspected/serviced. <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> TANK ID : TANK ID : 91 <br /> B .tank number, stored product, etc $7 ]�(Bvtanknuimber, stored roduct, etc. <br /> ❑x In-Tank Gauging (SW Tank) MAG 2 x❑ In-Tank Gauging (SW Tank) MAG 2 <br /> ❑x Annular Space or Vault Sensor 420 ❑x Annular Space or Vault Sensor 420 <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> ❑x Mechanical LLD 99 LD 2000 0 Mechanical LLD 99 LD 2000 <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑x Sump Sensor 208x❑ Sump Sensor 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 /> j Vent Piping Vent Piping <br /> El Sensor (Piping) El VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> E Vapor Recovery Piping Vapor Recovery Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> El Sensor E] Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> TANK ID : DIESEL TANK ID : <br /> (By tank number, stored product, etcj (By tank number, stored product, etc. <br /> In-Tank Gauging (SW Tank) MAG 2 ❑ In-Tank Gauging (SW Tank) <br /> NAnnular Space or Vault Sensor 420 E] Annular Space or Vault Sensor <br /> E] VPH Sensor El VPH Sensor <br /> Product Piping Product Piping <br /> ZMechanical LLD 99 LD 2000 E] Mechanical LLD <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) El VPH Sensor (Piping) <br /> 9Sump Sensor 208 El Sump Sensor <br />" ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> ❑ VPH Sensor (Piping) El 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 /> ID = Identification, SW = Single-Walled, VPH = Vacuum/PressureMydrostatic, LLD = Line Leak Detector <br />