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11 10,111gogm <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTFM r. ;=PTIMATION FORM (Page 2 of 8) <br /> Vi . INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System Certification Form must be prepared for each monitoring system control panel <br /> KVee:der <br /> of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed <br /> Root TLS 350 333 . 05 <br /> eck thea ro riate boxes to indicate specific equipment ins ected/serviced. <br /> Monitoring Device Used I Device Model # Monitoring Device Used I Device Model # <br /> TANK ID : TANK ID : <br /> 8 tank number, stored product, etc) Unleaded B tank number, stored product, etc)Plus <br /> �® In-Tank Gauging (SW Tank) VR 847390- 107 ® In-Tank Gauging (SW Tank) VR 847390-107 <br /> ® Annular Space or Vault Sensor Ronan LS-3 ® Annular Space or Vault Sensor VR 794390-420 <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> ❑ Mechanical LLD ® Mechanical LLD RJ 116-057-5 <br /> ® Electronic LLD 8484 ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor VR 794380-208 ® Sump Sensor VR 794380-208 <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> ❑ VPH Sensor ( Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor VR 794380-208 ® Sump Sensor VR 794380-208 <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 /> ❑ VPN Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Monitoring Device_ Used Device Model # Monitorin Device Used Device Model # <br /> TANK ID : TANK ID : <br /> 3-Premium 4- Diesel <br /> ( By tank number, stored product, etc.2 fBytank number, stored product, etc.) <br /> ® in-Tank Gauging (SW Tank) VR 847390- 107 ® In-Tank Gauging (SW Tank) VR 847390- 107 <br /> ® Annular Space or Vault Sensor RonanLS-3 ® Annular Space or Vault Sensor Ronan LS-3 <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> ❑ Mechanical LLD ® Mechanical LLD VMI LD2000 <br /> ® Electronic LLD 8484 ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor VR 794380-208 ® Sump Sensor VR 794380-208 <br /> ❑ VPH Sensor (Sump) <br /> El VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor VR 794380-208 ® Sump Sensor VR 794380-208 <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 /> ID = Identification, SW = Single-Walled, VPH = VacuunyPressureNWrostatic, LLD = Line Leak Detector <br /> i <br /> i(E <br /> E <br />