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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) VI. INVENTORY OF EQUIPMENT CERTIFIED ID =Identification, SW= Single-Waged, VPH = VacuumlPressureMydrostatiG LLD =Line Leak Detect A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. Make of Monitoring System Control Panel VEEDER ROOT Model of Monitoring System Control Panel TLS 350 Software Version Installed 329.01 Check the appropriate boxes to indicate specific a ui ment inspected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID:TANK B tank number, stored product, etc. 87 ❑x In-Tank Gauging (SW Tank) MAG 1 ID: 91 (By tank number, storedproduct, etc. Z In-Tank Gauging (SW Tank) MAG 1 ❑x Annular Space or Vault Sensor 409 Z Annular Space or Vault Sensor 409 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑x Mechanical LLD FE PETRO 9 Mechanical LLD FE PETRO ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ 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) Device Model # Monitoring Device Used Device Model # Monitoring Device Used TANK ID:TANK B tank number, stored product, etc. DSL ❑x In-Tank Gauging (SW Tank) MAG 1 ID: (By tank number, stored product, etc. ❑ In-Tank Gauging (SW Tank) ❑x Annular Space or Vault Sensor 407 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor. Product Piping Product Piping ❑x Mechanical LLD RED JACKET ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) qgj ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑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) or