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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 TLS 350 323 . 03 Check the appLo riate boxes to indicatespecific equipment ins ected/serviced. MonitoringDevice Used Device Model # Monitorin Device Used Device Model # TANK ID : TANK ID : 91 B .tank number, stored product, etc87 (By tank number, stored product, etc. ❑x In-Tank Gauging (SW Tank) MAG 1 9 In-Tank Gauging (SW Tank) MAG 7 ❑x Annular Space or Vault Sensor 302 9 Annular Space or Vault Sensor 302 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping x❑ Mechanical LLD 99 LD 2000 9 Mechanical LLD F E PETRO ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 208 ❑x Sump Sensor 208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 208 ❑x Sump Sensor 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 E ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) i ❑ Sump Sensor ❑ Sump Sensor F1 VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Model # i TANK ID : DIESEL TANK ID : B tank number, stored product, etc. 8 tank number, stored product, etc. ZIn-Tank Gauging (SW Tank) MAG 1 [I In-Tank Gauging (SW Tank) NAnnular Space or Vault Sensor 302 E] Annular Space or Vault Sensor El Sensor El VPH Sensor Product Piping Product Piping ZMechanical LLD F E PETRO E] Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ZSump Sensor 208 E] Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPN Sensor (Piping) ❑ VPH Sensor (Piping) ZSump Sensor 208 El Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) El Sensor E] Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) FEI SumpSensor ElSump Sensor VPH Sensor (Sump) ❑ VPH Sensor (Sump) eMydrostatic, LLD Line Leak Detector ID = Identification, SW = Single Wated, VPH = VacuumlPressur =