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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM Pae 2 of s <br /> VI . INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitor)ng System Certification Form must be prepared for each monitoring system control panel. <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed <br /> Veeder-Root TLS-350 130.01 <br /> _Check the appropriate boxes to Indicate specific equipment Inspected/serv)ced <br /> Monitoring Device Used I Devlce odea # Monitoring Device Used I Device Model # <br /> TanklD : T1 AST Tank ID * T2 UST <br /> B tenk number stored product, etc. 1 (By tank nu ber stored product, eta <br /> O In-tank Gauglnq (SW Tankl Mag 1 FV] In-tank Gauginq (SW Tank) Mag 1 <br /> Q Annular Space or vault sensor 794380420 W Annular Space or Vault Sensor 794380-303 <br /> ❑ VPH Sensor n VPH Sensor <br /> Product Piping Product Piping <br /> n Mechanical LLD n Mechanical LLD <br /> F-1 Electronic LLD ❑ Electronic LLD <br /> (� VPH Sensor (Piping) n VPH Sensor (Pining) <br /> n Sump Sensor 794380-208 n Sump Sensor 794380-208 <br /> F] VPH Sensor (Sump) n VPH Sensor (Sump) <br /> Fill Piving Fill <br /> F1 VPH Sensor (Piping) n VPH Sensor (Piping) <br /> n Sump Sensor 794380"208 I I Sump Sensor <br /> F] VPH Sensor (Sump) n VPH Sensor (Sump) <br /> Vent Piping Vent Piping <br /> VPH Sensor (Piping I ] VPH Sensor.(Piping) <br /> n Sump Sensor ❑ Sump Sensor <br /> t <br /> n VPH Sensor (Sump) n VPH Sensor tSuma) <br /> i <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> n VPH Sensor (Plying) n VPH Sensor (Piping) <br /> ❑ Sump Sensor n Sump Sensor <br /> F1 VPH Sensor (Sump} n VPH Sensor (Sump) <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> Tank ID : Tank ID <br /> (By tank number stored product, c.) (By tank number, stored roduct etc. <br /> n In-tank Gauging (SW Tank) n In-tank Gauging (SW Tank) <br /> ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor <br /> n VPN Sensor n VPH Sensor <br /> Product Pi in Product Pi in <br /> � Mechanical LLD ❑ Mechanical LLD <br /> n Electronic LLD n Electronic LLD <br /> ❑ VPH Sensor (Piping ) i�l VPH Sensor (Piping) <br /> n Sump Sensor F] Sump Sensor <br /> ❑ VPH Sensor (Sump) n VPH Sensor (Sump) <br /> Fill Piping Fill Pi in <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor n Sump Sensor <br /> [� VPH Sensor (Sump) n VPH Sensor (Sump] <br /> Vent Piping Vent Piping <br /> ❑ VPH Sensor (Piping) n VPH Sensor (Piping ) <br /> ❑ Sump Sensor n Sump Sensor <br /> F1 VPH Sensor (Sump) n VPH Sensor (Sump) <br /> Va or Recovery Piping Va or Recove Pi in <br /> n VPH Sensor (Piping) n VPH Sensor (Piping) <br /> n Sump Sensor n Sump Sensor <br /> n VPH Sensor (SUmpj ❑ VPH Sensor (Sump) <br />