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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s of s) Monitoring Device Used Device Model # Monitoring Device Used Device Model # VENT I TRANSITION SUMP ID : VENT I TRANSITION SUMP ID : ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor ❑ VPH Sensor UDC ID : 23M ID : 23S ❑x Electronic Sensor 794380-208 [:UDC Z Electronic Sensor 794380 -208 0 Mechanical Device Shear Valve N Mechanical Device Shear Valve ❑ VPH Sensor ❑ VPH Sensor UDC ID : 24M UDC ID : 24S Z Electronic Sensor 794380-208 ❑x Electronic Sensor 794380 -208 Z Mechanical Device Shear Valve Z Mechanical Device Shear Valve ❑ VPH Sensor ❑ VPH Sensor UDC ID : 25M UDC ID : 25S Z Electronic Sensor 794380-208 Z Electronic Sensor 794380-208 ❑x Mechanical Device Shear Valve X Mechanical Device Shear Valve ❑ VPH Sensor ❑ VPH Sensor UDC ID : 26M UDC ID : 26S ❑x Electronic Sensor 794380-208 ❑p Electronic Sensor 794380 -208 ❑x Mechanical Device Shear Valve ❑x Mechanical Device Shear Valve ❑ VPH Sensor ❑ VPH Sensor Other Monitored Component ID : Other Monitored Component ID : ❑ Other (Specify in section Vll.) ❑Other (Specify in section Vll.) Other Monitored Component ID : Other Monitored Component ID : ❑Other (Specify in section Vll.) ❑Other (Specify in section Vll.) Other Monitored Component ID : Other Monitored Component ID : ❑ Other (Specify in section Vll.) ❑ Other (Specify in section Vll.) Include information for every underground storage tank component monitored by this monitoring system control panel. If the monitoring system control panel monitors more components than this form accommodates, additional copies of these pages may be attached. VII . COMMENTS Use this section to provide additional comments about the inventory of the equipment certified. ID = Identification, VPH = Vacuum/Pressure/Hydrostatic, UDC = Under-Dispenser Containment