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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 Fonn must be prepared for each monitoring system control panel Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed j Veeder-Root TLS-350 133.06 Check the appropriate boxes to Indicate specific equipment inspected/serviced. Monitoring Device Used Device Model # monitoring Device Used Device Model # Tank ID : T1 - Diesel Tank We B tank number stored product, eta. 8 tank umber stored roduct etc, In tank Gauging fSW Tank) Mag 1 ❑ In-tank Gauaina jSW Tank) K Annular Space or Vault Sensor 794390-409 ❑ Annular Space or Vault Sensor ❑ VPH Sensor LLVP Sensor Product Pining Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD J ❑ VPH Sensor (Piping) ❑ VPN Sensor (PlpIn 01 q1 Su .p Sensor 794380-208 ❑ Sump Sensor F1VPH Sensor (Sump ) ❑ VPH Sensor (Sump) Fill Piping Fill PipingI ❑ VPH Sensor (EipIng) ❑ VPH Sensor (Piping) D Sump Sensor 0Sump Sensor ❑ VPH Sensor (Sump) n VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) F1 VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) F] VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery P( pina F] VPH Sensor (Piping) ❑ VPH Sensor ft m) ❑ Sump Sensor ❑ Sump Sensor F1 VPH Sensor (Sump) F1VPH Sensor (Sump) Monitoring Device Used Device Model # Monitorina Device Used Device Model # Tank ID : Tank ID: (By tank number, stored product. etc. ) (By tank number, stored product, etc. ❑ in-tank Gauging jSW Tank} n In-tank Gaug(ng tSW Tank} ❑ Annular Space or Vault Sensor ❑ Annular Spaceor Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Ph3lnq Product PI in ❑ Mechanical LLD ❑ Mechanical LLD n Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping ) ❑ VPH Sensor (Piping mp ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor. (Sump) Fill Piping Fill Piping . . (-1 VPH Sensor (Piping) ❑ VPH Sensor (Pl in) ❑ Sump Sensor O Sump Sensor �] VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Pi in ❑ VPH Sensor (Piping) n VPH Sensor (Pip(ng) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump ) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recove Pi in VPH Sensor (Piping) F-1 VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor El VPH Sensor (Sump) ❑ VPH Sensor (Sump)