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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of s) 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 VEEDER ROOT Model of Monitoring System Control Panel TLS - 350 Software Version Installed 335.00 Check the appropriate boxes to indicate specific equipment ins ected/serviced. Monitorin Device Used Device Model # Monitoring Device Used Device Model # TANK ID: (By tank number, stored product, etc.) 1 - DIESEL # 2 TANK ID: (Bv tank number, stored product, etc. 2 - 91 OCTANE ❑x In -Tank Gauging (SW Tank) M A G 7 ❑x In -Tank Gauging (SW Tank) M A G 1 ❑x Annular Space or Vault Sensor 4 0 9 ❑x Annular Space or Vault Sensor 4 0 9 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD 0 Electronic LLD P L L D - 8 4 8 4 ❑x Electronic LLD P L L D - 8 4 8 4 ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) x❑ Sump Sensor 2 0 8EI Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 2 0 8 ❑x Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑X Sump Sensor 2 0 8 ❑x Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑x Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: (By tank number, stored product, e 3 -87 OCTANE TANK ID: (By tank number, stored product, etc. ❑x In -Tank Gauging (SW Tank) M A G 1 ❑ In -Tank Gauging (SW Tank) ❑x Annular Space or Vault Sensor 4 0 9 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑x Electronic LLD PLLD - 8 4 8 4 ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) 9 Sump Sensor 2 0 8 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 2 0 8 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 2 0 8 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) 0 Sump Sensor 2 0 8 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) ID = Identification, SW= Single -Waled, VPH = VacuumlPressureMydrostatic, LLD = Line Leak Detector