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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM ( Page 2 of 6) <br /> VI . INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed <br /> GILBARCO E M C 16 . 04 <br /> Check the appropriate boxes to indicatespecific equipment ins ected/serviced. <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> TANK ID : 1 - 87 OCTANE TANK ID : 2 - 91 OCTANE <br /> (By tank number, stored product, etc. (Bv tank number, stored product, etc. <br /> ❑x In-Tank Gauging (SW Tank) MAG 2 Z In-Tank Gauging (SW Tank) M A G 2 <br /> 9 Annular Space or vault Sensor 4 2 0 Z Annular Space or vault Sensor 4 2 0 <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> ❑x Mechanical LLD V M I - LD 2000 0 Mechanical LLD V M I - LD 2000 <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑x Sump Sensor 2 0 8 Z Sump Sensor 2 0 $ <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Vent Piping Vent Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑x Sump Sensor 2 0 $ N Sump Sensor 2 0 $ <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> 0 Sump Sensor 2 0 $ Z Sump Sensor 2 0 8 <br /> ❑ VPH Sensor (Sump) I ❑ VPH Sensor (Sump) <br /> Monitoring Device- IJ ed Device Model # Monitoring Device Used Device Model # <br /> TANK ID : 3 - DIESEL # 2 TANK ID : <br /> (By tank number, stored product, etc.) (BY tank number, stored product, etc. <br /> ❑x In-Tank Gauging (SW Tank) M A G 2 ❑ In-Tank Gauging (SW Tank) <br /> ❑x Annular Space or Vault Sensor SHARED W/ 91 OCT ❑ Annular Space or vault Sensor <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> ❑x Mechanical LLD V M I - LD 2000 ❑ Mechanical LLD <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑x Sump Sensor 2 0 8 ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Vent Piping Vent Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑x Sump Sensor 2 0 $ ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> ID = Identification, SW = Single-Waged, VPH = Vacuum/Pressure/Hydrostatic, LLD = Line Leak Detector <br />