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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) Vi. INVENTORY OF EQUIPMENT CERTIFIED A separate Monitoring System Certiflcation 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 TLS35OR 334 . 00 Check theappropriate boxes to indicate s ecific equipment ins ected/servicer!. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: T1 •Unleaded TANK ID: T2-Unleaded (By tank number, stored product, etc.) (By lank number, stored product etc. ❑x In•Tank Gauging (SW Tank) 846390- 107 ❑p In-Tank Gauging (SW Tank) 84$390- 107 CI Annular Space or Vault Sensor 794390409 O Annular Space or vault Sensor 794390409 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) 21 Sump sensor 794380-208 21 Sump Sensor 794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) (9 Sump Sensor 794380-208 Sump Sensor 794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) p Sump Sensor 794380=208 91 Sump sensor 794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) p Sump Sensor 794380-208 21 Sump Sensor 794380 -208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) WIN Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: T-3 Unleaded TANK T4 -Premium (By tank number, storedproduct, e (gy lank number, stored product etc. 21 In-Tank Gauging (SW Tank) 846390= 107 ❑ In4ank Gauging (SW Tank) 846390- 107 x❑ Annular Space or vault sensor 794390-409 Annular Space ar Vault Sensor 794390 -409 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping s E] Mechanical LLD ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑p Sump sensor 794380-208 sump Sensor 794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑p Sump Sensor 794380-208 sump sensor 794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) p sump sensor 794380=208l sump sensor 794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) I ❑ VPH Sensor (Piping) x❑ Sump Sensor 794380-208 O sump sensor 794380 -208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) ID = Identification, SW = Single Walled. VPH = Va LLD = Line Leak Detector i i