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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. Version Installed Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Gilbarco EMC 330 . 01 Check the appropriate boxes to indicate specific equipment inspected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : 1 =87 TANK ID : 2 .91 (By tank number, stored product, e (By tank number, stored product, etc. ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) Z Annular Space or Vault Sensor 0794380-303 E Annular Space or Vault Sensor 0794380 -303 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping 0 Mechanical LLD VMI 99LD000 Z Mechanical LLD FE Petro STP- MLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 0794380-208 Z Sump Sensor 0794380-208 ❑ 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) ❑ VPN Sensor (Sump) Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : rANK ID : 8 tank number, stored product, etc. tank number, stored roduct, etc.ElIn-Tank Gauging (SW Tank) n-Tank Gauging (SW Tank) [ ❑ Annular Space or Vault Sensor ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑ Electronic LLD El ! Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) El Sensor El Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPN Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor El VPH Sensor (Sump) [:1VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) ID = Identification, SW = Single-Walled, VPH = VacuumlPressumftdrostatic, LLD = Line leak Detector i 1