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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 indicate specific equipment inspected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : Tank #5 DSL 12 ' 000 TANK ID : Tank #6 DSL 12 ' 000 B 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 794390420 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑x 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 #7 DSL 12 , 000 TANK ID : Tank #H BIO DSL 12 , 000 (B 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 794390-420 ❑x Annular Space or Vault Sensor 794390 -420 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑x 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