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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 pane/ Make of Monitoring System Control Paneldel of Monitoring System Control Panel Software Version Installed :TF VEEDER ROOT TLS 350 323 . 03 Check the appropriate boxes to indicate specific equipment ins ected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : 87 TANK ID : 91 (By tank number, stored product, etc. 8 tank number, stored roduct, etc. • In-Tank Gauging (SW Tank) MAG 1 Z In-Tank Gauging (SW Tank) MAG 7 ❑x Annular Space or Vault Sensor 302 0 Annular Space or Vault Sensor 302 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping El Mechanical LLD 99 LD 2000 X Mechanical LLD F E PETRO ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) Z Sump Sensor 208 p Sump Sensor 208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 208 N Sump Sensor 208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ 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) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitorin Device Used Device Model # Monitoring Device Used Device Model # TANK ID : DIESEL TANK ID : (By tank number, stored product, etcj (By tank number, stored product, etc. • In-Tank Gauging (SW Tank) MAG 1 ❑ In-Tank Gauging (SW Tank) ❑x Annular Space or Vault Sensor 302 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping g Mechanical LLD F E PETRO ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 208 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 208 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ 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) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) j ID = Identification, SW = Single-Walled, VPH = VacuumlPressureMydrostafic, LLD = Line Leak Detector I i