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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 VEEDER ROOT ::11TLS-350 Model of Monitoring System Control Panel Software Version Installed 324.02 Check the appropriate boxes to indicatespecific equipment ins ected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: (By tank number, stored product, e 1 - 91 OCTANE TANK ID: (By tank number, stored product, etc. 2 - 87 OCTANE 0 In -Tank Gauging (SW Tank) M A G 1 0 In -Tank Gauging (SW Tank) M A G 1 0 Annular Space or Vault Sensor 4 2 0 0 Annular Space or Vault Sensor 4 2 0 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping 0 Mechanical LLD F X - 1 V Z Mechanical LLD 99 LD 2000 ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) 0 Sump Sensor 2 0 8 0 Sump Sensor 2 0 8 ❑ 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: (By tank number, stored product, etc.) 3 - DIESEL #2 TANK ID: (By tank number, stored product, etc. 0 In -Tank Gauging (SW Tank) M A G 1 ❑ In -Tank Gauging (SW Tank) 0 Annular Space or Vault Sensor 4 2 0 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping 0 Mechanical LLD F X - 2 ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) 0 Sump Sensor 2 0 8 ❑ 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 = Single -Walled, VPH = Vacuum/Pressure/Hydrostatic, LLD = Line Leak Detector