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Underground Storage Tank <br />Monitoring System Certification Form <br />List only sensors tested on date of this certification. List "Sensor ID" as labeled in system <br />programming. Additional copies of this page may be attached to accommodate all sensors tested. <br />Describe all answers marked "No" or "Fail" and proposed remedy in Section 9. <br />List all monitoring equipment either replaced or repaired in Section <br />Sensor lD <br />Sensor Model <br />Component(s) Monitored <br />Pass <br />Fail <br />Input -1 <br />LS -610 <br />Annular Space <br />® <br />❑ <br />Input -2 <br />LS -600 <br />Fill Sump <br />® <br />❑ <br />Input -3 <br />LS -600 <br />Transition Sump <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />9 <br />Page 3 of 6 <br />