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i 6 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM ( Page 2 of 6) <br /> VI . INVENTORY OF EQUIPMENT CERTIFIED <br /> FA parate 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 /> VEEDER ROOT TLS 350 327 . 01 <br /> Check the appropriate boxes to indicate specific equipment ins ected/serviced. <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> TANK ID : 87 TANK ID : 91 <br /> (By tank number, stored product, e (Bv tank number, stored product, etc. <br /> ❑x In-Tank Gauging (SW Tank) MAG 1 Z In-Tank Gauging (SW Tank) MAG 1 <br /> p Annular Space or vault Sensor 420 p Annular Space or Vault Sensor 420 SPLIT W/DI E <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> ❑x Mechanical LLD 99 LD 2000 0 Mechanical LLD RED JACKET <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑x Sump Sensor 208 ❑x Sump Sensor 20 $ <br /> ❑x VPH Sensor (Sump) 304 Z VPH Sensor (Sump) 304 <br /> Fill Piping Fill Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑x Sump Sensor 208 x❑ Sump Sensor 20 $ <br /> ❑x VPH Sensor (Sump) 304 Z VPH Sensor (Sump) 304 <br /> Vent Piping Vent Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> El Sensor El Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> I Vapor Recovery Piping Vapor Recovery Piping <br /> I <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) L ❑ VPH Sensor (Sump) <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> TANK ID : DIESEL TANK ID : <br /> B tank number, stored product, etc. B tank number, stored product, etc. <br /> ❑x In-Tank Gauging (SW Tank) MAGI <br /> El In-Tank Gauging (SW Tank) <br /> ❑x Annular Space or Vault Sensor 420 El Annular Space or Vault Sensor <br /> El Sensor EJ VPH Sensor <br /> Product Piping Product Piping <br /> Mechanical LLD 99 LD 2000 E] Mechanical LLD <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> 9Sump Sensor 208 El Sump Sensor <br /> ❑x VPH Sensor (Sump) 304 ❑ VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> 9Sump Sensor 208 El Sump Sensor <br /> Z VPH Sensor (Sump) 304 El 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 = VacuumlPressureMydrostatc, LLD = Line Leak Detector <br /> 1 <br />