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Underground Storage Tank <br />Monitoring System Certification Form <br />Tank ID: <br />Sensor ID <br />Sensor Model <br />Component(s) Monitored <br />Pass <br />Fail <br />0 <br />208/304 <br />Vent sump/brine <br />❑ <br />❑ <br />L8 <br />304 <br />1/2 brine <br />❑ <br />❑ <br />L9 <br />208 <br />1/2 <br />❑ <br />❑ <br />L10 <br />304 <br />3/4 brine <br />❑ <br />❑ <br />L11 <br />208 <br />3/4 <br />❑ <br />❑ <br />L12 <br />304 <br />5/6 brine <br />❑ <br />❑ <br />L13 <br />208 <br />5/6 <br />® <br />❑ <br />L14 <br />304 <br />7/8 brine <br />® <br />❑ <br />L15 <br />208 <br />7/8 <br />® <br />❑ <br />L16 <br />304 <br />9/10 brine <br />® <br />❑ <br />U DCs: <br />Sensor lD <br />Sensor Model <br />Component(s) Monitored <br />Pass <br />Fail <br />0 <br />208/304 <br />Vent sump/brine <br />® <br />❑ <br />L8 <br />304 <br />1/2 brine <br />N <br />❑ <br />L9 <br />208 <br />1/2 <br />® <br />❑ <br />L10 <br />304 <br />3/4 brine <br />® <br />❑ <br />L11 <br />208 <br />3/4 <br />® <br />❑ <br />L12 <br />304 <br />5/6 brine <br />® <br />❑ <br />L13 <br />208 <br />5/6 <br />® <br />❑ <br />L14 <br />304 <br />7/8 brine <br />® <br />❑ <br />L15 <br />208 <br />7/8 <br />® <br />❑ <br />L16 <br />304 <br />9/10 brine <br />® <br />❑ <br />L17 <br />208 <br />9/10 <br />® <br />❑ <br />L18 <br />208 <br />11/12 <br />® <br />❑ <br />L19 <br />304 <br />11/12 brine <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />El <br />1-1 <br />Describe all answers marked "No"or "Fail" and proposed remedy in Section 9. <br />List al/ Monitoring equipment either replaced or repaired in Section 9. <br />Page 5 of 9 <br />