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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM 'Page 2 of 6) VI. INVENTORY OF EQUIPMENT CERTIFIED ID = Identification, SW = Single -Walled, VPH = VacuurrdPressureJl-lydrostati 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 I Software Version Installed Pnumercator TM&2,000 IN/A Check the appropriate boxes to indicatespecific equipment ins ected/serviced. Monitoring Device Used Device Model # Monitoripq Device Used Device Model # TANK ID: MANTECA/Diesel/ B tank number, stored product, etc.) B In -Tank Gauging (SW Tank) MP -400 TANK ID: (By tank number, stored product, etc. ❑ In -Tank Gauging (SW Tank) 0 Annular Space or Vault Sensor LS -610 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor LS -600 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) 0 Sump Sensor ❑ VPH Sensor (Sump) LS -600 ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ 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 ❑ VPH Sensor (Sump) ❑ Sump Sensor ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: (By tank number, stored product, etc. ❑ In -Tank Gauging (SW Tank) TANK ID: (By tank number, stored product, e ❑ In -Tank Gauging (SW Tank) ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ 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 ❑ 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) ❑ VPN Sensor (Sump) c, LLD =Line Leak Detector