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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 panel. Make of Monitoring System Control Panel =TLS350 ring System Control Panel Software Version Installed Veederoot 334 . 01 Check the appropriate boxes to indicate specific equipment inspected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank ID : #'1 -Supreme Tank ID : #2- Diesel (By tank number, stored product, e (By tank number, stored product, etc. ❑ In-tank Gauging (SW Tank) ❑ In-tank Gauging (SW Tank) ® Annular Space or Vault Sensor 794390-303 ® Annular Space or Vault Sensor S lit tank-see Supreme ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ® Electronic LLD P . L . L . D . ® Electronic LLD P . L . L . D . ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) M Sump Sensor 794380 -208 ® Sump Sensor 794380 - 208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor 794380 - 208 ® Sump Sensor 794380 - 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) Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank ID : #3- Regular Tank ID : (By tank number, stored product, e (Bv tank number, stored product, etc. ❑ In-tank Gauging (SW Tank) ❑ In-tank Gauging (SW Tank) ® Annular Space or Vault Sensor 794390 -303 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ® Electronic LLD P . L . L . D . ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor 794380- 208 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor 794380 -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) ID = Identification, SW = Single walled, VPH = Vacuum/Pressure/Hydrostatic, LLD = Line leak detector