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Jul , 2 . 2019 3 . 05PM Donlee Pump Co No . 2195 P . 3 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) <br /> VL INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System Cerdfrcation Form must be prepared for each Monttorl»y system control panel. <br /> Make of Monitoring System control Panel Model of Monitoring System Control Panel Software Version Installed <br /> Veeder Root TLS-360 329 . 01 <br /> Check the appropriate boxes to indicate SpeCttlC Qq ulpment inspected/servtood. <br /> Monitorin Device Used DevlCe M9de1 k Monitorin Device Used Device Model # <br /> Tank ID. Unleaded 87 Tank 1D ; Unleaded - 91 <br /> (By tank number, stored psroduqdt, eP I C (By tank number, stored ipisodUot, etc. <br /> N In-lank Gauging (SW Tank) Mag Probe N In. tank Gauging (SW Tank) Maq Probe <br /> R Annular Space or Vejult Sensor VR-407 R Annular space or Vault Sensor VR-407 <br /> ❑ VPH sensor d VPH ,Sensor <br /> Product Piping ProdU it PI In <br /> N Mechanical LLD Red Jacket N Mechanical LLD ERedcket <br /> El5lectronk ; LLD El Electronic LLD <br /> ❑ VPH Sensor (Piping) Q VPH Sensor (Piping)Sump Sensor VR-208 N Sump Sensor <br /> ❑ VPH sensor (sump) E) VPH Sensor (Sump) <br /> FIII PI in Fill Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> [IVPH Sensor (Sump) d VPH Sensor (Sump) <br /> Vent Piping Vent Pipin <br /> IN ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> Sump Sensor ❑ Sump Sensor <br /> ❑ VPH sensor (Sump) ❑ VPH Sensor (Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑ VPH Sensor (Piping) tj VPH Sensor (Plping) <br /> d sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Surnp) ❑ VPH $ensor (sump) <br /> Monitoring Device Used Device Model ft Monitoring,Devlco Used Device Model # <br /> S Tank IDS Clear Dleael Tank ll): <br /> (By tank number, stored product e (By tank number, stow) r4ducf, etc. <br /> N In-tank Gauging (SW Tank) Mag Probe ❑ In-tank Gauging (SW Tank) <br /> ® Annular Space or Vault Sensor VR407 ❑ Annular Space or Vault Sensor <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> El Mechanical LLD Red Jacket ❑ Mechanlral LLD <br /> ❑ Elecironle LLD Q Eleotronlo LLD <br /> ❑ VPH Sensor (Piping) Q VPN sensor (Piping) <br /> M sump Sensor VR-208 ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Fill Piping Fill Pt In <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> E] Sump Sensor ❑ sump Sensor <br /> ElVPH Sensor (Sump) L) VPH Sensor (Sump) <br /> Vent Piping Vent Piping <br /> ❑ VPN Sensor (Piping) ❑ VPH Sensor (Plp(ng) <br /> © sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Vapor Recovery Pi in Va or Re <br /> cove Piping <br /> ❑ VPH Sensor (Piping) VPH Sensor (Piping) <br /> 0 sump Sensor ❑ Sump Sensor <br /> I <br /> Q VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> t <br /> E( <br /> AJ�a +.a.at.. 11 A = 1ln.. t..nU d..irv.fAr <br /> E <br />