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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) VI . INVENTORY OF EQUIPMENT CERTIFIED 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 Software Version Installed Veeder- Root TLS 350 334 . 01 Check the appropriate boxes to indicatespecific equipment ins ected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : Tank #1 Unleaded 16 , 000 Gallons TANK ID : Tank #2 Premium 9 , 000Gallons (By tank number, stored product, etcj (By tank number, stored product, etc. ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) Q Annular Space or vault Sensor 79438MW/S lit with 91 Z Annular Space or Vault Sensor 79438MM/S lit with 87 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping Z Mechanical LLD VMI LD2000 Z Mechanical LLD VMI LD2000 ❑ Electronic LLD ❑ Electronic LLD Q VPH Sensor (Piping ) 330020-463/330020 -464 0 VPH Sensor (Piping ) 330020463/330020 -464 • Sump Sensor 794380 -208 0 Sump Sensor 794380-208 p VPH Sensor (Sump) 794380- 304 0 VPH Sensor (Sump) 794380-304 Fill Piping Fill Piping ❑ VPH Sensor (Piping ) ❑ VPH Sensor ( Piping ) • Sump Sensor 794380 -208 Z Sump Sensor 794380-208 ❑x VPH Sensor (Sump) 794380 - 304 0 VPH Sensor (Sump) 794380-304 Vent Piping Vent Piping Z VPH Sensor (Piping ) 330020463/330020464 0 VPH Sensor ( Piping ) 330020463/330020464 ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑X VPH Sensor (Piping ) 330020463/330020464 ❑ 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 : TANK ID : (By tank number, stored product, etc.) (BY tank number, stored product, etc. ❑ In-Tank Gauging (SW Tank) ❑ 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) ❑ VPH Sensor (Sump) ID = Identification, SW =S ingle-Walled,V PH= Vacuum/Pressure/Hydrostatic, LLD = Line Leak Detector