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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 monitoring system control paneL <br />Make of Monitoring System Control Panel <br />Gilbarco <br />Model of Monitoring System Control Panel <br />Veeder Root TLS 350 <br />Software Version Installed <br />127.04 <br />Check the appropriate boxes to indicate specific equipment inspected/serviced. <br />Monitoring Device Used I Device Model # Monitoring Device Used I Device Model # <br />TANK ID: <br />(By tank number, stored product, etc.) Diesel TANK ID: <br />(By tank number, stored product, etc.) <br />0 In-Tank Gauging (SW Tank) 847390 - 109 In-Tank Gauging (SW Tank) <br />zi Annular Space or Vault Sensor 0794390 - 420 0 Annular Space or Vault Sensor <br />III VPH Sensor 0 VPH Sensor <br />Product Piping Product Piping <br />III Mechanical LLD 0 Mechanical LLD <br />Electronic LLD 0 Electronic LLD <br />M VPH Sensor (Piping) 0 VPH Sensor (Piping) <br />N Sump Sensor 0794380 - 205 Sump Sensor <br />MI VPH Sensor (Sump) D VPH Sensor (Sump) <br />Fill Piping Fill Piping <br />0 VPH Sensor (Piping) 0 VPH Sensor (Piping) <br />0 Sump Sensor 0 Sump Sensor <br />VPH Sensor (Sump) 0 VPH Sensor (Sump) <br />Vent Piping Vent Piping <br />MI VPH Sensor (Piping) 0 VPH Sensor (Piping) <br />III Sump Sensor D Sump Sensor <br />II VPH Sensor (Sump) 0 VPH Sensor (Sump) <br />Vapor Recovery Piping Vapor Recovery Piping <br />IN VPH Sensor (Piping) El VPH Sensor (Piping) <br />El Sump Sensor 0 Sump Sensor <br />0 VPH Sensor (Sump) 0 VPH Sensor (Sump) <br />Monitorin9 Device Used Device Model # Monitoring Device Used Device Model # — <br />TANK ID: <br />(By tank number, stored product, et) <br />TANK ID: <br />B tank number stored .roduct, etc. <br />0 In-Tank Gauging (SW Tank) III In-Tank Gauging (SW Tank) <br />Annular Space or Vault Sensor 0 Annular Space or Vault Sensor <br />0 VPH Sensor lil VPH Sensor <br />Product Piping Product Piping <br />0 Mechanical LLD MI Mechanical LLD <br />0 Electronic LLD Electronic LLD <br />0 VPH Sensor (Piping) 0 VPH Sensor (Piping) <br />Sump Sensor M Sump Sensor <br />VPH Sensor (Sump) / 0 VPH Sensor (Sump) <br />Fill Piping Fill Piping <br />VPH Sensor (Piping) 0 VPH Sensor (Piping) <br />D Sump Sensor D Sump Sensor <br />0 VPH Sensor (Sump) 0 VPH Sensor (Sump) <br />Vent Piping Vent Piping <br />0 VPH Sensor (Piping) 0 VPH Sensor (Piping) <br />0 Sump Sensor Sump Sensor <br />0 VPH Sensor (Sump) III VPH Sensor (Sump) <br />Vapor Recovery Piping Vapor Recovery Piping <br />M VPH Sensor (Piping) VPH Sensor (Piping) <br />III Sump Sensor Sump Sensor <br />VPH Sensor (Sump) 0 VPH Sensor (Sump) <br />ID = Identification, SW= Single-Walled, VPH = Vacuum/Pressureillydrostatic, LLD = Line Leak Detector