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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 Model of Monitoring System Control Panel Software Version Installed Veeder- Root TLS -350 333 . 04 Check the appropriate boxes to indicate specific equipment inspected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank ID : T1 Unleaded 87A Tank ID : T2 Unleaded 87B (By tank number, stored product, e (By tank number, stored product, etc. ® In-tank Gauging (SW Tank) Mag PIUS ® In-tank Gauging (SW Tank) Mag Plus ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ® Electronic LLD Veeder- Root PLLD ® Electronic LLD Veeder- Root PLLD ® VPH Sensor (Piping) 332117 ® VPH Sensor (Piping ) 332117 ® Sump Sensor 794380- 112 ® Sump Sensor 794380- 112 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ® VPH Sensor (Piping) 332117 ® VPH Sensor (Piping ) 332117 ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ® VPH Sensor (Piping ) 332117 ® VPH Sensor (Piping ) 332117 ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping M VPH Sensor (Piping ) 332117 ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank lD : T3 Unleaded 91 Tank ID : T4 Additive (By tank number, stored product, etc. ) (By tank number, stored product, etc. ® In-tank Gauging (SW Tank) Mag Plus ® In-tank Gauging (SW Tank) Mag PIUS ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Pi in Product Piping ❑ Mechanical LLD M Mechanical LLD Fe- Petro ® Electronic LLD Veeder- Root PLLD ❑ Electronic LLD ® VPH Sensor (Piping ) 332117 M VPH Sensor (Piping ) 332117 ® Sump Sensor 794380 - 112 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping M VPH Sensor (Piping) 332117 ❑ VPH Sensor (Piping ) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping M VPH Sensor (Piping) 332117 M VPH Sensor (Piping ) 332117 _ ❑ Sump Sensor ❑ Sump Sensor s �) El VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor ( Piping ) ❑ VPH Sensor (Piping ) I I I ti ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) ,.... _ fie.° t' ID = Identification, SW = Single-walled, VPH = Vacuum/Pressure/Hydrostatic, LLD = Line leak detector