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Jan . 23 . 2019 7 % 47AM Donlee Pump Co No - 1366 P . 3 R UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of s) Vl. INVENTORY OF EQUIPMENT CERTIFIED A separate Monitoring System Cerifficatlon Porm must be prepared for each monitoring system control panel. Make of Monitoring System Control Panel Model of Monitoring System Control Penal Software Version Installed Check the appropriate boxes to fnd/cats specific equipment ced. Monitoring Device Used I Device Model # Monitoring Device Used Device Model # Tank ID: Tank ID: ' (By tatiknunlber stored roduof, etc. B fahknurnber stoned roduof, eto PIP ❑ -tank Gauging (SW Tank) $4 pro In-lank Gauging (SirtrTank) I VgSA IPIP Annular Space or Vauit Sensor � ( Q. Annular Space 4r Vauil SensorII.ZQ ❑ VPN Sensor ❑ VPH Sensor' ProductPiping , Product Piping ❑ Mechanloal LLD ❑ Mechanical LLD Lj 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) Q VPH Sensor (Piping) EJSump Sensor (] Sump Sensor [IVPH Sensor (Sump) El VPH Sensor (Sump) Vent Pipina Vent Piping 41, ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) s ❑ Sump Sensor d Sump Sensor El Sensor {Sump} [I VPH Sensor (Sump) n Vapor Recovery Piping Vapor Reoovery Piping El Sensor (Piping) El VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) [l VPH Sensor (Sump) Monitorin D*vice Used Device Model # Monitoring beVice Used Device Model # Tank ID ; Tank IDS (By fork number, stored prmoduct e (By tat)ltnumber, stored produot etc. NIP ❑ In4ank Gauging (SW Tank) ❑ In-lank Gauging (SW Tenk) ❑ Annular Space or Vault Sensor ❑ Annular Space or Vaull Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanicai LLD ❑ Mechanieal LLD Q Electronic LLD ❑ Electronic LLD Ij VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor Q VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) Int VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) a Vent Piping Vent PI In t . ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ElVPH Sensor (Sump) Vapor Recovery Piping vapor Recove PI In [I VPH Sensor (Piping) ❑ VPH Sensor (Piping) © Sump Sensor Sump Sensor ❑ VPH Sensor (Sump) ❑ VPN Sensor (Sump) II'1v l.tu.,frfiralinn SWe1411vdn M11Pd VIP" Va1`J 11 .n7fflaLw lre%ftdrostatic. LLD = Line leak detector '..