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ID =Identificati UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page z of 6) VI. INVENTORY OF EQUIPMENT CERTIFIED A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. Make of Monitoring System Control Panel VEEDER ROOT Model of Monitoring System Control Panel TLS 350 Software Version Installed 331.02 Check the appropriate boxes to indicate specific equipment inspected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: 87 1 B tank number, storedproduct, etc. • In -Tank Gauging (SW Tank) IVIAU vi TANK ID: 87 � 2 B tank number, stored product, etc. 0 In -Tank Gauging (SW Tank) IVIAU wI ❑x Annular Space or Vault Sensor 4LU ❑x Annular Space or Vault Sensor 42U ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑x Electronic LLD F'LLU ❑x Electronic LLD t'LLU ❑x VPH Sensor (Piping) El VPH Sensor (Piping) El Sump Sensor LUQ 0 Sump Sensor LUti ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Device Model # Monitoring Device Used Device Model # Monitoring Device Used TANK ID: 91 (By tank number, stored product, etc.) TANK ID: (By tank number, stored product, etc. ❑x In -Tank Gauging (SW Tank) IVIAU 1 ❑ In -Tank Gauging (SW Tank) 0 Annular Space or Vault Sensor 4zu ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑x Electronic LLD t'LLU ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) (] Sump Sensor LUtS ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) on, SW = Single -Walled, VPH = VacuurrUPressureMydrostatic, LLD =Line Leak Detector