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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 = VacuumlPressureil-lydrosta6c, LLD =Line Leak Detect A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. Make of Monitoring System Control Panel VEEDER ROOT Model of Monitoring System Control Panel TLS 350 Software Version Installed 334.01 Check the appropriate boxes to indicatespecific equipment ins ected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: 87_1 (By tank number, stored product, etc.) TANK ID: 87_2 (Bv tank number, stored product, etc. ❑x In -Tank Gauging (SW Tank) MAG -1 0 In -Tank Gauging (SW Tank) MAG -1 x❑ Annular Space or Vault Sensor 407 ❑x Annular Space or Vault Sensor. 407 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑x Electronic LLD PLLD ❑x Electronic LLD PLLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) * Sump Sensor 352 ❑x Sump Sensor 352 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) 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 ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Device Model # Monitoring Device Used Device Model # Monitoring Device Used TANK ID: 91 B tank number, storedproduct, etc. TANK ID: 8 tank number, storedproduct, etc. ❑x In -Tank Gauging (SW Tank) MAG -1 ❑ In -Tank Gauging (SW Tank) ❑x Annular Space or Vault Sensor 407 ❑ Annular Space or Vault Sens . . ❑ VPH Sensor ❑ VPH Sensor s Product Piping Product Piping r ` ❑ Mechanical LLD 0 Electronic LLD PLLD ❑ Mechanical LLD ❑ Electronic LLD ❑ VPN Sensor (Piping) ❑ VPH Sensor (Piping) Z Sump Sensor 352 ❑ Sump Sensor[ VIROOMENTAL HEAL 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) F ,:.-2 . ITkP1 F N1T Fill Piping Fill Piping m ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) x❑ Sump Sensor 208 ❑ 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) or