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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) <br /> VI. INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed <br /> Gilbarco/Veeder Root EMC/TLS-350 333.03 <br /> Check ::1 <br /> the appropriate boxes to indicate specific equipment inspected/serviced. <br /> —F- <br /> MonitoringDevice Used Device Model# MonitoringDevice UsedDevice Model# <br /> TANK ID:01 Req TANK ID: 02 Prem <br /> (By tank number,stored product,etc.) (By tank number,stored product,etc. <br /> ❑ In-Tank Gauging(SW Tank) ❑ In-Tank Gauging(SW Tank) <br /> 0 Annular Space or Vault Sensor VR 794390-420 0 Annular Space or Vault Sensor VR 794390-460 <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> 0 Mechanical LLD RJ 116-056-5 ✓❑ Mechanical LLD RJ 116-056-5 <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ✓❑Sump Sensor VR 794380-208 ✓❑Sump Sensor VR 794380-208 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> 0 Sump Sensor VR 794380-208 0 Sump Sensor VR 794380-208 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Monitoring Device Used Device Model# —Monitoring Device Used Device Model# <br /> TANK ID: 03 Diesel TANK ID: <br /> (By tank number,stored product,e (By tank number,stored product,etc. <br /> ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) <br /> 0 Annular Space or Vault Sensor VR 794390-460 ❑Annular Space or Vault Sensor <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> 0 Mechanical LLD Vaporless LD2000 ❑Mechanical LLD <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> 0 Sump Sensor VR 794380-208 ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ✓❑Sump Sensor VR 794380-208 ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> ID=Identification,SW=Single-Walled,VPH=VacuunUPressure/Hydrostatic,LLD=Line Leak Detector <br />