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Underground Storage Tank <br />Monitoring System Certification Form <br />[A&I:10R'Nza9=IIIki100:&II10 <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 lD <br />Sensor Model <br />Component(s) Monitored <br />Pass <br />Fail <br />L 1 <br />208 <br />87 STP SUMP <br />0 <br />❑ <br />L 2 <br />409 <br />87 ANNULAR SPACE <br />0 <br />❑ <br />L 3 <br />208 <br />91 STP SUMP <br />0 <br />❑ <br />L 4 <br />409 <br />91 ANNULAR SPACE <br />0 <br />❑ <br />L 5 <br />208 <br />DISPENSER 1-2 <br />0 <br />❑ <br />L 6 <br />208 <br />DISPENSER 3-4 <br />0 <br />❑ <br />L 7 <br />208 <br />DISPENSER 5-6 <br />0 <br />❑ <br />L 8 <br />208 <br />DISPENSER 7-8 <br />0 <br />❑ <br />L 9 <br />208 <br />DISPENSER 9-10 <br />0 <br />❑ <br />L 10 <br />208 <br />DISPENSER 11-12 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <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 />