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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page 3 of 6) Monitoring Device Used Device Model # Monitorin Device Used Device Model # VENT / TRANSITION SUMP ID : VENT / TRANSITION SUMP ID : ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor ❑ VPH Sensor UDC ID : 1 /2 UDC ID : 5/6 ❑ Electronic Sensor ❑ Electronic Sensor Mechanical Device Dispensers 1 -8 have floats and chains . 0 Mechanical Device Dispensers 1 -8 have floats and chains . ❑ VPH Sensor ❑ VPH Sensor UDC ID : 3/4 UDC ID : 7/8 ❑ Electronic Sensor ❑ Electronic Sensor ❑x Mechanical Device Dispensers 1 -8 have floats and chains. ❑x Mechanical Device Dispensers 1 -8 have floats and chains . ❑ VPH Sensor ❑ VPH Sensor UDC ID : UDC ID : ❑ Electronic Sensor ❑ Electronic Sensor ❑ Mechanical Device ❑ Mechanical Device ❑ VPH Sensor ❑ VPH Sensor UDC ID : UDC ID : ❑ Electronic Sensor ❑ Electronic Sensor ❑ Mechanical Device ❑ Mechanical Device ❑ VPH Sensor ❑ VPH Sensor Other Monitored Component ID : Other Monitored Component ID : ❑ Other (Specify in section Vll.) ❑ Other (Specify in section Vll.) Other Monitored Component ID : Other Monitored Component ID : ❑ Other (Specify in section Vll.) ❑ Other (Specify in section Vll.) Other Monitored Component ID : Other Monitored Component ID : ❑ Other (Specify in section Vll.) ❑ Other (Specify in section Vll.) Include information forevery underground storage tank component monitoredby this monitoring system controlpane/. If the monitoring system control panel monitors more components than this form accommodates, additional copies of these pages may be attached. Vii . COMMENTS Use this section to provide additional comments about the inventory of the equipment certified Dispensers 1 -8 have floats and chains . ID = Identification, VPH = VacuumJPressure/Hydrostatic, UDC = Under-Dispenser Containment UN - 107 www. unidocs . org 3/6 - Rev. 10 /01 /18 I I