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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 of s) <br /> VI. INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed <br /> auto stick jr 4 <br /> Check the appropriate boxes to indicate specific equipment ins ected(serviced. <br /> MonitoringDevice Used Device Model# Monitoring Device Used Device Model# <br /> TANK ID: 87 TANK ID: 91 <br /> (By tank number,stored pruduct,etc.) (By tank number,stored product,etc. <br /> ❑x In-Tank Gauging(SW Tank) MAG ❑x In-Tank Gauging(SW Tank) <br /> ❑x Annular Space or Vault Sensor ULS ❑x Annular Space or Vault Sensor ULS <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> ❑x Mechanical LLD red jacket x❑Mechanical LLD fe petro <br /> ❑Electronic LLD ❑Electronic LLD <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> 0 Sump Sensor ULS ❑x Sump Sensor ULS <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Monitoring Device Used Device Model# -Monitoring Device Used Device Model# <br /> TANK ID: TANK ID: <br /> B tank number,storedproduct,etc. B tank number,storedproduct,etc. <br /> ❑In-Tank Gauging(SW Tank) ❑In-Tank Gauging(SW Tank) <br /> ❑Annular Space or Vault Sensor ❑Annular Space or Vault Sensor <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> ❑Mechanical LLD ❑Mechanical LLD <br /> ❑Electronic LLD ❑Electronic LLD <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> ID=Identification,SW=Single-Waled,VPH=VacuunvPressureMydrostatic,LLD=Line Leak Detector <br />