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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) VI. INVENTORY OF EQUIPMENT CERTIFIED ID =Identification, SW A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. Make of Monitoring System Control Panel VEEDER ROOT Model of Monitoring System Control Panel T L S- 3 5 0 Software Version Installed 334.00 Check the appropriate boxes to indicate specific equipment ins ected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: 87 OCT - WEST B tank number, storedproduct, etc. N In -Tank Gauging (SW Tank) M A G 1 TANK ID: 87 OCT - CENTER B tank number, storedproduct, etc. Z In -Tank Gauging (SW Tank) M A G 1 x❑ Annular Space or Vault Sensor 4 0 9 Z Annular Space or Vault Sensor 4 0 9 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD N Electronic LLD P L L D- 8 4 8 4 ❑ Electronic LLD SYPHON ONLY ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 2 0 8 ❑x Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 3 2 3 0 Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) N Sump Sensor 2 0 8 N Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) I ❑ VPH Sensor (Piping) N Sump Sensor 2 0 8 N Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Device Model # Monitoring Device Used Device Model # Monitoring Device Used TANK ID: 87 OCT- EAST (By tank number, stored product, etc. Z In -Tank Gauging (SW Tank) M A G 1 TANK ID: 4 - 91 OCTANE (By tank number, stored product, etc. I] In -Tank Gauging (SW Tank) M A G 1 x❑ Annular Space or Vault Sensor 4 0 9 ❑x Annular Space or Vault Sensor 4 0 9 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD x❑ Electronic LLD SHARED LINE ❑x Electronic LLD P L L D- 8 4 8 4 ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) N Sump Sensor 3 2 3 X Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) N Sump Sensor 3 2 3 ❑x Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) N Sump Sensor 3 2 3 ❑x Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) N Sump Sensor 3 2 3 ❑x Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑VPH Sensor (Sump) = Single -Walled, VPH = VacuurnlPressure.MydrostatiG LLD Line Leak Detector =