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UNDERGROUND STORAGE TANK ` MONITORING SYSTEM CERTIFICATION FORM ( Page 2 of 6) VL 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 Check the appropriate boxes to indicatespecific equipment inspected/serviced Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : 1`4 /Diesel/4,000 TANK ID : (By tank number, stored product, etcj (Bv tank number, stored product, etc. Ij In-Tank Gauging (SW Tank) MP 405 -088-25 ❑ In-Tank Gauging (SW Tank) 0 Annular Space or Vault Sensor LS -610 ❑ Annular Space or Vault Sensor ❑ VPN Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping ) ❑ VPH Sensor ( Piping ) p Sump Sensor LS-600 ❑ 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 LS-600 ❑ 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 ID : (By tank number, stored product, e (By tank number, stored pmduct, 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) ONEi j ID = Identification, SW = Single-Walled, VPH = Vacuum/PressuWiydrostatic, LLD = Line Leak Detector i s