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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 /> RONAN / VEEDER ROOT X 76 S / TLS - 350 -- / 126 . 02 <br /> Check the appropriate boxes to indicate s ecific a ui ment ins ected/serviced. <br /> MonitoringDevice Used Device Model # Monitorin Device Used Device Model # <br /> TANK ID : 1 - KEROSENE I TANK ID : 2 - 100 OCTANE <br /> (By tank number, stored product, etcj I (By tank number, stored product, etc. <br /> ❑x In-Tank Gauging (SW Tank) M A G 1 N In-Tank Gauging (SW Tank) M A G 1 <br /> ❑x Annular Space or vault Sensor L - S - 3 Z Annular Space or Vault Sensor L - S - 3 <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> ❑x Mechanical LLD VMI - LD 2000 Z Mechanical LLD RED JACK - X L D <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑x Sump Sensor 2 0 8 Z Sump Sensor 2 0 8 <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 /> 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 /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> TANK ID : TANK ID : <br /> (By tank number, stored product, e (By tank number, stored product, etc. <br /> ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) <br /> ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor <br /> I <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> t ❑ Mechanical LLD ❑ Mechanical LLD <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> El Sensor (Piping) El VPH Sensor (Piping) <br /> El Sensor E] Sump Sensor <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 /> Vent Piping Vent Piping <br /> El Sensor (Piping) El VPH Sensor (Piping) <br /> ❑ Sump Sensor <br /> E] 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/Pressure/Hydrostatic, LLD = Line Leak Detector <br />