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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) VI. INVENTORY OF EQUIPMENT CERTIFIED ID =Identification, SW= Single -Walled, VPH = VacuumlPressureh-iydrostatic, LLD =Line Leak Detect 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 inspected/serviced Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: 87 OCT - WEST (By tank number, stored product, e TANK ID: 87 OCT- CENTER (By tank number, stored product, etc. 0 In -Tank Gauging (SW Tank) M A G 1 Z 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 P L L D- 8 4 8 4 ❑ Electronic LLD SYPHON ONLY ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 2 0 8 Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) El 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) ❑x Sump Sensor 2 0 8 ❑x Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) I ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑VPH Sensor (Piping) Sump Sensor 2 0 8 ❑D Sump Sensor 2 0 8 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID: 87 OCT- EAST (By tank number, stored product, etc.) ❑x In -Tank Gauging (SW Tank) M A G 1 TANK ID: 4 - 91 OCTANE (By tank number, stored product, etc. In -Tank Gauging (SW Tank) M A G 1 x❑ Annular Space or Vault Sensor 4 0 9 Q Annular Space or Vault Sensor 4 0 9 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD I] Electronic LLD SHARED LINE ❑D Electronic LLD P L L D- 8 4 8 4 ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 3 2 3 1 M Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 3 2 3 [] Sump Sensor 3 2 3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x 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) ❑x Sump Sensor 3 2 3 p Sump Sensor 3 2 3 ElVPH Sensor (Sump) ❑ VPH Sensor (Sump) or