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Underground Storage Tank <br />Monitoring System Certification Form <br />TESTING RESULTS <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 />Sensor ID <br />Sensor Model <br />Component(s) Monitored <br />Pass <br />Fail <br />L 1 <br />303 <br />87 ANNULAR <br />❑ <br />L 2 <br />208 <br />87 FILL SUMP <br />O <br />❑ <br />L 3 <br />304 <br />87 FILL BRINE <br />D <br />❑ <br />L 4 <br />208 <br />87 STP SUMP <br />p <br />❑ <br />L 5 <br />303 <br />87 STP BRINE <br />0 <br />❑ <br />L 6 <br />303 <br />91 AND DIESEL ANNULAR <br />21 <br />❑ <br />L 7 <br />208 <br />91 FILL <br />0 <br />❑ <br />L8 <br />304 <br />91 FILL BRINE <br />0 <br />❑ <br />L 9 <br />208 <br />91 STP <br />0 <br />❑ <br />L 10 <br />304 <br />91 STP BRINE <br />D <br />❑ <br />L 11 <br />208 <br />DIESEL FILL <br />❑ <br />L 12 <br />304 <br />DIESEL FILL BRINE <br />ID <br />❑ <br />L 13 <br />208 <br />DIESEL STP <br />ID <br />❑ <br />L 14 <br />304 <br />DIESEL STP BRINE <br />El <br />❑ <br />L 15 <br />208 <br />DISP 1-2 <br />0 <br />❑ <br />L 16 <br />304 <br />DISP 1-2 BRINE <br />[D <br />❑ <br />L 17 <br />208 <br />DISP 3-4 <br />0 <br />❑ <br />L 18 <br />304 <br />DISP 3-4 BRINE <br />0 <br />❑ <br />L 19 <br />208 <br />DISP 5-6 <br />El <br />❑ <br />L 20 <br />304 <br />DISP 5-6 BRINE <br />0 <br />❑ <br />L 21 <br />208 <br />DISP 7-8 <br />0 <br />❑ <br />L 22 <br />304 <br />DISP 7-8 BRINE <br />0 <br />❑ <br />L 23 <br />208 <br />VENT BOX <br />0 <br />❑ <br />L 24 <br />304 <br />VENT BOX BRINE <br />B <br />❑ <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 9 <br />Page 3 of 6 <br />