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Rug , 30 . 2019 MW Donlee Pump Co No . 256 $ P . 3 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) <br /> Vi . INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System CeHincation Form must be prepared for eaolt monitoring system control panel. <br /> Mak of Monitor! i Panel Model of Monitoring System Control Panei SoKwars Version Installed <br /> Vee �M <br /> Check fire appiappriate boxes to Indicate specift a ul ment fns ected/seravloed• <br /> Monitoring Device Used DevicO Model # Monitorin Device U ed Device Meda( # <br /> Tank ID; � + y . ` ' Tank ID: f '1dett <br /> { <br /> t k n ber st roduo , t . fAnn <br /> tank num a , sore ro uc etc. <br /> n lank Gauging (SW Tank) ank Gauging (SW Tank) <br /> Annular Space or Vault Sensor ular Space or Vault Sensor dad <br /> El VPH Sensor ❑ VPH Sensor <br /> Product Piping proilloct Piping <br /> Mechanical LLD ancka i4voobanical LLD <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ' ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> avSump Sensor ump Sensor <br /> ❑ VPH Sensor (Sump) a ❑ VPH Sensor (Sump) <br /> FIII Piping FIII Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> l ❑ Sump Sensor ❑ Sump Sensor <br /> 0 VPH Sensor (Sump) d VPH Sensor (Sump) <br /> Vent I' ipin Vent P{ In <br /> ❑ VPH Sensor (Piping) ❑ VPN Sensor (Piping) <br /> ❑ Sump Sensor [] Sump Sensor <br /> d VPH Sensor (Sump) I3 VPH Sensor (Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping IMF <br /> [� VPH Sensor (Piping) F., ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor I] Sump Sensor IF <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> Tank ID : Tank ID; <br /> 8 fenknumbor stored roduct, Alo ) (By lank number, storedmoduct etc. <br /> [IIn-tank Gauging (SW Tank) din-lank Gauging (SW Tank) <br /> ❑ Annular Space or Vautt Sensor ❑ Annular Space at Vault Sensor <br /> ❑ VPH Sensor 0 VPN Sensor <br /> Product Piping Product Piping <br /> ❑ Mechanloal LLD ❑ Mechanical LLD <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPN Sensor (Piping) 1 ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump sensor <br /> Ij VPH Sensor (Sump) IF ❑ VPH Sensor (Sump) IF <br /> FIII Piping Fill PI in I at <br /> ❑ VPH Sensor (Piping) ❑ VPN Sensor (Piping) <br /> © Sump Sensor Q Sump Sensor <br /> ❑ VPH Sensor (Sump) FVentPlping or (Sump) <br /> Vent Piping❑ VPH Sensor (Piping) or (Piping) <br /> ❑ Sump Sensor sor <br /> ❑ VPH Sensor (Sump) or (Sump) <br /> Va or .Recove Piping Vapor Recove PI In <br /> ❑ VPH Sensor (Piping) <br /> b VPH Sensor (Piping) <br /> ❑ Sump Sensor Ij Sump Sensor <br /> ❑ VPN Sensor (Sump) ❑ VPH Sensor (Sump) <br /> I� IF v Ivan an .Iv . r w I . . . . . n . 60 s m, a _ a 1_ _. .. ,.,11'f.a. ..,.n.in .,i.an..�..tiw 111't � l I �n tacit �Ic4onfrY <br />