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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 3 of 6) <br /> Monitoring Device Used Device Model# Monitoring Device Used Device Model# <br /> Vent/Transition Sump ID: Additive Vent Sump Vent/Transition Sump ID: <br /> ® Sump Sensor 794380-323 ❑ Sump Sensor <br /> ®VPH Sensor 794380-304 ❑VPH Sensor <br /> UDC ID: 1 & 2 UDC ID: 3 &4 <br /> ® Electronic Sensor 794380-208 ® Electronic Sensor 794380-208 <br /> ® Mechanical Device OPW Shear Valve ® Mechanical Device OPW Shear Valve <br /> ❑VPH Sensor ❑VPH Sensor <br /> UDC ID: 5 & 6 UDC ID: 7 & 8 <br /> ® Electronic Sensor 794380-208 ® Electronic Sensor 794380-208 <br /> ® Mechanical Device OPW Shear Valve ® Mechanical Device OPW Shear Valve <br /> ❑VPH Sensor ❑VPH Sensor <br /> UDC ID: 9 & 10 UDC ID: 11 & 12 <br /> ® Electronic Sensor 794380-208 ® Electronic Sensor 794380-208 <br /> ® Mechanical Device OPW Shear Valve ® Mechanical Device OPW Shear Valve <br /> ❑VPH Sensor ❑VPH Sensor <br /> UDC ID: UDC ID: <br /> ❑ Electronic Sensor ❑ Electronic Sensor <br /> ❑ Mechanical Device ❑ Mechanical Device <br /> ❑VPH Sensor ❑VPH Sensor <br /> UDC ID: UDC ID: <br /> ❑ Electronic Sensor ❑ Electronic Sensor <br /> ❑ Mechanical Device ❑ Mechanical Device <br /> ❑VPH Sensor ❑VPH Sensor <br /> UDC ID: UDC ID: <br /> ❑ Electronic Sensor ❑ Electronic Sensor <br /> ❑ Mechanical Device ❑ Mechanical Device <br /> ❑VPH Sensor ❑VPH Sensor <br /> Other Monitored Component ID: Other Monitored Component ID: <br /> ❑ Other(Specify in section Vll.) I ❑ Other(Specify in section Vll.) <br /> Other Monitored Component ID: Other Monitored Component ID: <br /> ❑ Other(Specify in section Vll.) I ❑ Other(Specify in section Vll.) <br /> Other Monitored Component ID: Other Monitored Component ID: <br /> ❑ Other(Specify in section Vll.) I ❑ Other(Specify in section Vll.) <br /> Include information for every underground storage tank component monitored by this monitoring system control panel. If the monitoring <br /> system control panel monitors more components than this form accommodates,additional copies of these pages may be attached. <br /> VII. COMMENTS <br /> Use this section to provide any additional comments about the inventory of the equipment certified. <br /> T4 Additive has a shared Fill and STP Sump. Fill Sump sensors are covered in Piping sump listing. <br /> ID=Identification,VPH=Vacuum/Pressure/Hydrostatic,UDC=Under-dispenser containment <br />