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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Pag ;2of s) VI . INVENTORY OF EQUIPMENT CERTIFIED A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. Software Version Installed Make of Monitoring System Control Panel Model of Monitoring sysTLSm Contro3501 Panel 329 , 01 VEEDER ROOT Check the qp ro riate boxes to indicates ecific a ui ment inspected/serviced. Device Model # MonitoringDevice Used Device Model # Monitoring Device Used TANK ID : 1 = 87 OCTANE TANK ID : 2 - 89 OCTANE B tank number, stored product, etc, a tank number, stored roduct, etc. rx In-Tank Gauging (SW Tank) M A G 1 (] In-Tank Gauging (SW Tank) M A G 1 (]x Annular Space or Vault Sensor 4 0 9 Q Annular Space or Vault Sensor 4 0 9 ❑ VPH Sensor El VPH Sensor Product Piping Product Piping 9 Mechanical LLD 99 LD 2000 0 Mechanical LLD 99 LD 2000 I' ❑ Electronic LLD F1 Electronic LLD ❑ VPH Sensor (Piping) El VPH Sensor (Piping) Z Sump Sensor 3 2 3 Sump sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) xp Sump Sensor 3 4 4 � Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) Z Sump Sensor 3 2 3 p Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) Zx Sump Sensor 3 2 3 p Sump Sensor 3 2 3 [I VPH Sensor (Sump) E] VPH Sensor (Sump) Monitorin Device Used Device Model # Monitorin Device Used Device Model # TANK ID : 3 - 91 OCTANE TANK ID : B tank number, stored product, etc. 8 tank number, stored product, etc. ❑ In-Tank Gauging (SW Tank) • In-Tank Gauging (SW Tank) MAG 1 0 Annular Space or Vault Sensor 4 0 9 ❑ Annular Space or Vault Sensor El Sensor F1 VPH Sensor PProduct Piping Product Piping Mechanical LLD 99 LD 2000 - NEW ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD 171VPH Sensor (Piping) El VPH Sensor (Piping) E] Sump Sensor p Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) E] Sump Sensor Rx Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) El VPH Sensor (Piping) ❑ Sump Sensor Fxj Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping El Sensor (Piping) El VPH Sensor (Piping) � Sump Sensor 3 2 3 E] Sump Sensor ❑ VPH Sensor (Sump) F1 VPH Sensor (Sump) ID = Identification, SW = Single-Walled, VPH = Vacuum/Pressure/Hydrostatic, LLD = Line Leak Detector