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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) <br /> VI. INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System Certification Form must be prepared for each monitorin system control panel. <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed <br /> Veeder Root TLS-350R <br /> Check the appropriate boxes to indicatespecific equipment inspected/serviced. <br /> Monitoring Device Used Device Model # Monitoring Device Used I Device Model # <br /> Tank ID: REG. Gasoline-Regular Tank ID: PREM. Gasoline-Premium <br /> (By tank number, stored product, etc.) (By tank number, stored product, etc.) <br /> rv-1 In-tank Gauging (SW Tank) MAG r In-tank Gauging (SW Tank) MAG <br /> I✓ Annular Space or Vault Sensor 794380-303 F%0_Annular Space or Vault Sensor 794380-303 <br /> 7 VPH Sensor r VPH Sensor <br /> Product Piping Product Pi in <br /> W Mechanical LLD LD-2000 FY-1 Mechanical LLD LD-2000 <br /> I- Electronic LLD r Electronic LLD <br /> r VPH Sensor(Piping) VPH Sensor(Piping) <br /> W Sump Sensor 794380-208 W Sump Sensor 794380-208 <br /> 7 VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> I- VPH Sensor(Piping) I_ VPH Sensor(Piping) <br /> Fy' Sump Sensor 794380-208 W Sump Sensor 794380-208 <br /> I-VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> r VPH Sensor(Piping) r VPH Sensor(Piping) <br /> r Sump Sensor r Sump Sensor <br /> F VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> r VPH Sensor(Piping) rVPH Sensor(Piping) <br /> I-Sump Sensor r Sump Sensor <br /> 17-VPH Sensor(Sump) [�VPH Sensor(Sump) <br /> Monitoring Device Used Device Model# Monitoring Device Used Device Model # <br /> Tank ID: DIESEL Diesel Tank ID: <br /> (By tank number, stored product, etc.) (By tank number, stored product, etc.) <br /> W In-tank Gauging(SW Tank) MAG In-tank Gauging(SW Tank) <br /> I�Annular Space or Vault Sensor 794380-303 r Annular Space or Vault Sensor <br /> (-VPH Sensor I VPH Sensor <br /> Product Piping Product Piping <br /> Mechanical LLD LD-2000 r Mechanical LLD <br /> Electronic LLD r Electronic LLD <br /> VPH Sensor(Piping) I-VPH Sensor(Piping) <br /> Sump Sensor 794380-208 r Sump Sensor <br /> IVPH Sensor(Sump) r VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> r- VPH Sensor(Piping) I- VPH Sensor(Piping) <br /> W Sump Sensor 794380-208 Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> I- VPH Sensor(Piping) I VPH Sensor(Piping) <br /> F Sump Sensor r Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> r VPH Sensor(Piping) I- VPH Sensor(Piping) <br /> r Sump Sensor r Sump Sensor <br /> I-VPH Sensor(Sump) r VPH Sensor(Sump) <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council <br />