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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 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 Model of Monitoring System Control Panel T333, 00ftware Version Installed VR TLS 350 5 _ _ Check the appropriate boxes to indicates specific equipment fns ected/serviced. Monitoring Device Used j _ Device Model # Monitoring Device Used I y Device Model #— TANK ID : 1-Unleaded TANK ID : 2-Premium By tank number, stored roduct, etc. ) {By tank number, stored product, etc. —❑ In-Tank Gauging (SW Tank) I ❑ In-Tank Gauging (SW Tank) ® Annular Space or Vault Sensor VR 794390420 0 Annular Space or Vault Sensor VR 794390-420 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping 0 Mechanical LLD RJ-116-056-5 0 Mechanical LLD LD 2000 ❑ Electronic LLD ❑ Electronic LLD E] VPH Sensor (Piping) F1 VPH Sensor (Piping) __— 0 Sump Sensor VR 794380-208 ® Sump Sensor VR 794380-208 ❑ VPH Sensor (Sump) ( — ❑ VPH Sensor (Sump) — — FFill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) _ _— _ ❑ VPH Sensor (Sump) Vent Piping Vent Piping ----- - -------El VPH 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) I ❑ VPH Sensor (Piping) ❑ Sump Sensor —1 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # — , Monitoring Device Used — ry- Device Model # — TANK ID : 3 Diesel TANK ID : (8y tank number, stored product, etc. ) B tank number, stored product, etc. l _ --- --- — ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) 0 Annular Space or Vault Sensor VR 794390-420 -- -- [I Annular Space or Vault Sensor -- [I VPH Sensor I [IVPH Sensor Product Piping Product Piping ® Mechanical LLD ( RJ-116-056-5 -- 4 ElMechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) �— - — - - ❑ VPH Sensor (Piping) ® Sump Sensor VR 794380-208 ❑ Sump Sensor ❑ VPH Sensor (Sump) { ❑ VPH Sensor (Sump) Fill Piping Fill Piping E] VPH Sensor (Piping) El VPH Sensor ( ❑ Sump Sensor ( ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) I Vent Piping Vent Piping - -- -- ❑ VPH Sensor (Piping) -- —_ _ ( ❑ VPH Sensor (Piping) ❑ Sump Sensor -- ❑ Sump Sensor El VPH Sensor (Sump) — — ❑ 11 VPH Sensor (Sump) — Vapor Recovery Piping € Vapor Recovery Piping --- ------- ❑ VPH Sensor (Piping) E] VPN Sensor (Piping) — ❑ Sump Sensor I I ❑ Sump Sensor I — — ❑ VPH Sensor (Sump) [I VPH Sensor (Sump) ID = Identification, SW= Single-Waled, VPH = Vaaxan+PreM'eh tydrostatic, LLD = Line Leak Detector