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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 350P . 332 . 00 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 Syphon Tank ID : T2 Unleaded 87B Master (By tank number, stored product, etc.) (By tank number, stored product, etc. ® In-tank Gauging (SW Tank) Mag 1 ® In-tank Gauging (SW Tank) Mag 1 ® Annular Space or Vault Sensor 794390 -409 ® Annular Space or Vault Sensor 794390 -409 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ® Mechanical LLD Red Jacket ® Mechanical LLD Shared with 87A tank ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor ( Piping ) ❑ VPH Sensor ( Piping ) ® Sump Sensor 794380 -208 ® Sump Sensor 794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump ) Fill Piping Fill Piping ❑ VPH Sensor (Piping ) ❑ VPH Sensor (Piping ) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor ( Piping ) ❑ VPH Sensor ( Piping ) ❑ 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) Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank ID : T3 Unleaded 91 Tank ID : (By tank number, stored product, etc.) (By tank number, stored product, etc. ® In-tank Gauging (SW Tank) Mag 1 ❑ In-tank Gauging (SW Tank) ® Annular Space or Vault Sensor 794390 -409 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ® Mechanical LLD FePetro ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor ( Piping ) ❑ VPH Sensor ( Piping ) M Sump Sensor 794380 -208 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump ) Fill Piping Fill Piping ❑ VPH Sensor ( Piping ) ❑ VPH Sensor ( Piping ) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump ) Vent Piping Vent Piping ❑ VPH Sensor (Piping ) ❑ VPH Sensor ( Piping ) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping El Sensor ( Piping ) El VPH Sensor ( Piping ) ❑ Sump Sensor [:1 Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump ) i i E i E in = Irlanfifirnfinn. SW = Sinrnla-wallarl. VPH = Vari II ImtPracCi ira/14vrlrncfafir_ i i n = I ina lack rlafarfnr