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UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM Waoe 2 of 61 <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 />Device Model # <br />Model of Monitoring System Control Panel <br />EMC <br />Software Version Installed <br />334.00 <br />Check the appropriate boxes to indicate specific equipment ins ected/serviced. <br />TANK ID: <br />8 tank number, storedproduct, etc. <br />Monitoring Device Used <br />Device Model # <br />Monitoring Device Used <br />Device Model # <br />TANK ID: <br />(By tank number, stored product, etc.) <br />87 <br />TANK ID: <br />(By tank number, stored product, etc. <br />91 <br />Q In -Tank Gauging (SW Tank) <br />MAG 1 <br />0 In -Tank Gauging (SW Tank) <br />MAG 1 <br />Q Annular Space or vault Sensor <br />407 <br />❑x Annular Space or vault Sensor <br />407 <br />❑ VPH Sensor <br />❑ Electronic LLD <br />❑ VPH Sensor <br />Product Piping <br />p Sump Sensor <br />Product Piping <br />❑ Sump Sensor <br />(] Mechanical LLD <br />99LD 2000 <br />D Mechanical LLD <br />99LD 2000 <br />❑ Electronic LLD <br />Fill Piping <br />❑ Electronic LLD <br />❑ VPH Sensor (Piping) <br />❑ Sump Sensor <br />❑ VPH Sensor (Piping) <br />❑ Sump Sensor <br />Z Sump Sensor <br />208 <br />p Sump Sensor <br />208 <br />❑ VPH Sensor (Sump) <br />Vent Piping <br />❑ VPH Sensor (Sump) <br />Fill Piping <br />❑ Sump Sensor <br />Fill Piping <br />❑ Sump Sensor <br />❑ VPH Sensor (Piping) <br />❑ VPH Sensor (Piping) <br />Vapor Recovery Piping <br />❑ Sump Sensor <br />Vapor Recovery Piping <br />❑ Sump Sensor <br />❑ VPH Sensor (Sump) <br />❑ Sump Sensor <br />❑ VPH Sensor (Sump) <br />❑ Sump Sensor <br />Vent Piping <br />Vent Piping <br />❑ VPH Sensor (Piping) <br />❑ VPH Sensor (Piping) <br />❑ Sump Sensor <br />❑ Sump Sensor <br />❑ VPH Sensor (Sump) <br />❑ VPH Sensor (Sump) <br />Vapor Recovery Piping <br />Vapor Recovery Piping <br />❑ VPH Sensor (Piping) <br />❑ VPH Sensor (Piping) <br />❑ Sump Sensor <br />❑ Sump Sensor <br />❑ VPH Sensor (Sump) <br />❑ VPH Sensor (Sump) <br />Monitoring Device Used <br />Device Model # <br />Monitoring Device Used Device Model # <br />TANK ID: <br />(By tank number, stored product, etc. <br />DSL <br />TANK ID: <br />8 tank number, storedproduct, etc. <br />• In -Tank Gauging (SW Tank) <br />MAG 1 <br />_ <br />❑ In -Tank Gauging (SW Tank) <br />❑x Annular Space or Vault Sensor <br />407 SPLIT WITH 91 <br />❑ Annular Space or vault Sensor <br />❑ VPH Sensor <br />❑ VPH Sensor <br />Product Piping <br />Product Piping <br />0 Mechanical LLD <br />99LD 2000 <br />❑ Mechanical LLD <br />❑ Electronic LLD <br />❑ Electronic LLD <br />❑ VPH Sensor (Piping) <br />❑ VPH Sensor (Piping) <br />p Sump Sensor <br />208 <br />❑ Sump Sensor <br />❑ VPH Sensor (Sump) <br />❑ VPH Sensor (Sump) <br />Fill Piping <br />Fill Piping <br />❑ VPH Sensor (Piping) <br />❑ VPH Sensor (Piping) <br />❑ Sump Sensor <br />❑ Sump Sensor <br />❑ VPH Sensor (Sump) <br />❑ VPH Sensor (Sump) <br />Vent Piping <br />Vent Piping <br />❑ VPH Sensor (Piping) <br />❑ VPH Sensor (Piping) <br />❑ Sump Sensor <br />❑ Sump Sensor <br />❑ VPH Sensor (Sump) <br />❑ VPH Sensor (Sump) <br />Vapor Recovery Piping <br />Vapor Recovery Piping <br />❑ VPH Sensor (Piping) <br />❑ VPH Sensor (Piping) <br />❑ Sump Sensor <br />❑ Sump Sensor <br />❑ VPH Sensor (Sump) <br />❑ VPH Sensor (Sump) <br />ID = Identification, SW = Single -Waled, VPH = Vacuum/PressureMydrostatic, LLD = Line Leak Detector <br />