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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 Model of Monitoring System Control Panel Software Version Installed <br /> Veeder Root TLS-350 355.05 <br /> Check the appropriate boxes to indicate specific equipment inspected/serviced. <br /> Monitoring Device Used T Device Model # Monitoring Device Used Device Model # <br /> Tank ID: 91 Gasoline-Premium Tank ID: ds] Diesel <br /> (By tank number, stored product, etc.) (By tank number, stored product, etc.) <br /> 17 In-tank Gauging (SW Tank) Mag W In-tank Gauging(SW Tank) Mag <br /> P-1 Annular Space or Vault Sensor 794380-303 I✓ Annular Space or Vault Sensor 794380-303 <br /> r VPH Sensor r VPH Sensor <br /> Product Piping Product Piping <br /> f Mechanical LLD 7 Mechanical LLD <br /> 17 Electronic LLD 848480-001 17 Electronic LLD 848480-001 <br /> I—VPH Sensor(Piping) r_ VPH Sensor(Piping) <br /> 91 <br /> ry Sump Sensor 794380-209 WSump Sensor 794380-209 <br /> f VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> I— VPH Sensor(Piping) I—VPH Sensor(Piping) <br /> W Sump Sensor 794380-209 W Sump Sensor 794380-209 <br /> Is VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> I—VPH Sensor(Piping) I—VPH Sensor(Piping) <br /> f Sump Sensor I—Sump Sensor <br /> F VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> [—VPH Sensor(Piping) r VPH Sensor(Piping) <br /> r Sump Sensor r Sump Sensor <br /> r VPH Sensor(Sump) r VPH Sensor(Sump) <br /> Monitoring Device Used Device Model# Monitoring Device Used Device Model# <br /> Tank ID: 87 Gasoline-Regular Tank ID: <br /> (By tank number, stored product, etc.) (By tank number, stored product, etc.) <br /> W In-tank Gauging (SW Tank) Mag In-tank Gauging (SW Tank) <br /> 17 Annular Space or Vault Sensor 794380-303 r Annular Space or Vault Sensor <br /> I—VPH Sensor VPH Sensor <br /> Product Piping Product Piping <br /> I Mechanical LLD I— Mechanical LLD <br /> W Electronic LLD 848480-001 1—Electronic LLD <br /> I_VPH Sensor(Piping) r—VPH Sensor(Piping) <br /> ry-0 Sump Sensor 794380-209 I—Sump Sensor <br /> r—VPH Sensor(Sump) 7 VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> F VPH Sensor(Piping) I— VPH Sensor(Piping) <br /> W Sump Sensor 794380-209 I—Sump Sensor <br /> F VPH Sensor(Sump) VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> I— VPH Sensor(Piping) r VPH Sensor(Piping) <br /> I— Sump Sensor 1—Sump Sensor <br /> F_VPH Sensor(Sump) f VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> f VPH Sensor(Piping) I+VPH Sensor(Piping) <br /> I—Sump Sensor r Sump Sensor <br /> I—VPH Sensor(Sump) r— Sensor(Sump) <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council <br />