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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 I Device Model # Monitoring Device Used Device Model # TANK ID : Tank # 1 Diesel 12 , 000 TANK ID : Tank #2 Diesel 12 , 000 8 tank number, stored product, etc. ' 8 tank number, stored product, etc.) ' ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) ❑x Annular Space or Vault Sensor 794390420 Z Annular Space or Vault Sensor 794390420 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping Q Mechanical LLD 99LD -3000 ❑ 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) Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : Tank #3 Diesel 12 , 000 TANK ID : � ank #4 Bio Diesel 12 00 (8 tank number, storedproduct, etc.) ' B tank number, storedproduct, etc. ' ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) ❑x Annular Space or Vault Sensor 794390420 ❑x Annular Space or Vault Sensor 794390 -420 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping [] Mechanical LLD 99LD - 3000 ❑ 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 i E