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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Pae z of s) A. 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 SystemControltrol Panel Software VersionInstalled VEEDER ROOT TANK ID: B tank number, stored roduct etc. 87 TANK ID: B tank number stored product etc. 91 ❑x In -Tank Gauging (SW Tank) MAG PLUS ZIn-Tank Gauging (SW Tank) MAG PLU ❑x Annular Space or Vault Sensor VR 303 ❑x Annular Space or vault Sensor VR 303 ❑ VPH Sensor VR 208 ❑ VPH Sensor ❑x VPH Sensor (Sump) Product Piping ❑ VPH Sensor (Sump) Product Piping ❑ Mechanical LLD[-] [E VPH Sensor (Piping) MechanicalLLD C] VPH Sensor (Piping) (] Electronic LLD VR PLLD E] Electronic LLD VR PLLC Z VPH Sensor (Piping) VR VAC I] VPH Sensor (Piping) VR VAC ZSump Sensor VR 208 ❑x Sump Sensor VR 208 ❑x VPH Sensor (Sump) VR 304 I] VPH Sensor (Sump) VR 304 Fill Piping ❑ VPH Sensor (Sump) Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) x❑ Sump Sensor VR 208 ❑x Sump Sensor VR 208 ❑x VPH Sensor (Sump) VR 304 ❑O VPH Sensor (Sump) VR 304 Vent Piping Vent Piping ❑x VPH Sensor (Piping) VR VAC 0 VPH Sensor (Piping) VR VAC ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovory Piping ❑x VPH Sensor (Piping) VR VAC Z VPH Sensor (Piping) VR VAC ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Moc TANK ID: (By tank number, stored Product, et DIESEL TANK ID: (By tank number, stored product, etc. ❑x In -Tank Gauging (SW Tank) MAG PLUS ❑ In -Tank Gauging (SW Tank) ❑x Annular Space or Vault Sensor VR 303 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD x❑ Electronic LLD VR PLLD ❑ Electronic LLD m % i n n r-1 VDLd Cone n, (Pininnl U vrn ornsui 1riNu IV) ❑x Sump Sensor v i ♦ v rw VR 208 ❑ Sump Sensor ZVPH Sensor (Sump) VR 304 ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑VPH Sensor (Piping) ❑x Sump Sensor VR 208 ❑ Sump Sensor ❑x VPH Sensor (Sump) VR 304 ❑ VPH Sensor (Sump) Vent Piping Vent Piping [E VPH Sensor (Piping) VR VAC C] VPH Sensor (Piping) C1 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 = Siigle-WaW, VPH = V LLD = Line Leak Detector