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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM 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 Model of Monitoring System Control Panel Software Version Installed Veeder- root TLS -350 15 . 05 Check the appropriate boxes to indicate specific equipment inspected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank ID * Tank ID : B tank number, stored roduct, etc. 87 B tank number, stored product, etc.) 89 ® In-tank Gauging (SW Tank) Mac Probe ® In-tank Gauging (SW Tank) Mac Probe E Annular Space or Vault Sensor 4. 07 0 Annular Space or Vault Sensor 407 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ® Mechanical LLD LD 2000 ® Mechanical LLD LD 2000 ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor 208 ® Sump Sensor 20 $ ❑ 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) El Sensor [:1 Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) i Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank ID : Tank ID : By tank number, stored roduct, etc.) 91 By tank number, stored product, etc. 0 In-tank Gauging (SW Tank) Maq Probe El In-tank Gauging (SW Tank) N Annular Space or Vault Sensor 407 [:1 Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping N Mechanical LLD LD 2000 ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) N Sump Sensor 208 El Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) El Sump Sensor El Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) El 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) ID = Identification, SW = Single-walled, VPH = Vacuum/Pressure/Hydrostatic, LLD = Line leak detector