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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 3 of 6) Monitoring Device Used Device Model # Monitorin Device Used Device Model # VENT / TRANSITION SUMP ID : VENT / TRANSITION SUMP ID : ❑ Sump Sensor [I Sump Sensor ❑ VPH Sensor ❑ VPH Sensor UDC ID : 16 UDC ID : 19 Main 9 Electronic Sensor 794380-208El Electronic Sensor 794380 -208 E] Mechanical Device ElMechanical Device ElVPH Sensor ❑ VPH Sensor UDC ID : 19 Sat JUD : 20 Main ❑x Electronic Sensor 794380-208 ectronic Sensor 794380-208 ❑ Mechanical Device echanical Device ❑ VPH Sensor ❑ VPH Sensor UDC ID : 20 Sat UDC ID : 21 Main x❑ Electronic Sensor 794380 -208 Z Electronic Sensor 794380 -208 ❑ Mechanical Device ❑ Mechanical Device ❑ VPH Sensor ❑ VPH Sensor UDC ID : 21 Sat UDC ID : 22 Main Z Electronic Sensor 794380-208 X Electronic Sensor 794380 -208 ❑ Mechanical Device ❑ Mechanical Device ❑ VPH Sensor ❑ VPH Sensor Other Monitored Component ID : Other Monitored Component ID : ❑ Other (Specify in section VII.) ❑ Other (Specify in section VII.) Other Monitored Component ID : Other Monitored Component ID : ❑ Other (Specify in section VII.) ❑ Other (Specify in section Vll.) Other Monitored Component ID : Other Monitored Component ID : ❑ Other (Specify in section Vll) ❑ Other (Specify in section VII.) Include information for every underground storage tank component monitored by this monitoring system control panel. If the monitoring system control panel monitors more components than this form accommodates, additional copies of these pages may be attached. VII . COMMENTS Use this section to provide additional comments about the inventory of the equipment certified. i i i I I i I ID = Identification, VPH = Vacuum/Pressure/Hydrostatic, UDC = Under-Dispenser Containment E