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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM Page 2 of s VL ` INVENTORY OF EQUIPMENT CERTIFIED A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. 01000000 Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed VEEDER ROOT TLS 350 Check the appropriate boxes to indicate specific equipment ins ected/serviced. Monitoring Device Used Device Model # MonitoringDevice Used Device Model # MEMNON TANK ID: 87 TANK ID: 91 (iqy tank number, stored product, etc.) (By tank number, stored prockict, etc. ❑x In-Tank Gauging (SW Tank) MAG-1 x❑ In-Tank Gauging (SW Tank) MAGA Annular Space or Vault Sensor 420 Annular Space or Vault Sensor 420 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑x Mechanical LLD FX IV Mechanical LLD LD2000 ❑ 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) ❑ 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) Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: DIESEL TANK ID : (Bv tank number, stored product, etcj (Bv tank number, stored prqduqt etc. ❑x In-Tank Gauging (SW Tank) MAGA ❑ In-Tank Gauging (SW Tank) Annular Space or Vault Sensor 420 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑x Mechanical LLD LD 2000 ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) j Sump Sensor 208 ❑ 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 E] 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) ID = Identification, SW = Single-Waled, VPH = VacutxWressure Hydrostatic, LLD = Line Leak Detector