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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 350 327 . 04 Check the appropriate boxes to indicatespecific a ui ment in ected/serviced. Monitoring Device Used Device Model # Monitorin Device Used Device Model # TANK ID : TANK ID : 91 8 tank number, stored product, etc. $ 7 (By tank number, stored product, etc. ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) ❑x Annular Space or Vault Sensor 420 Z Annular Space or Vault Sensor 420 ❑x VPH Sensor 001 E VPH Sensor 001 Product Piping Product Piping ❑x Mechanical LLD 99LD 2000 Z Mechanical LLD FXIV ❑ Electronic LLD ❑ Electronic LLD ❑x VPH Sensor (Piping) 001 El VPH Sensor (Piping) 001 ❑x Sump Sensor 208 x❑ Sump Sensor 208 • VPH Sensor (Sump) 304 Z VPH Sensor (Sump) 304 Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 208 ❑x Sump Sensor 20 $ ❑x VPH Sensor (Sump) 304 ❑x VPH Sensor (Sump) 304 Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor E] VPH Sensor (Sump) El VPH Sensor (Sump) Vapor Recovery Piping rE or Recovery Piping ❑ VPH Sensor (Piping) VPH Sensor (Piping) ❑ Sump Sensor Sump Sensor ❑ VPH Sensor (Sump) VPH Sensor (Sump) Monitoring Device Used Device Model # Monitorin Device Used Device Model # TANK ID : TANK ID : B tank number, stored product, etc. DSL 8 tank number, stored product, etc. ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) ❑x Annular Space or Vault Sensor 420 ❑ Annular Space or Vault Sensor NVPH Sensor 001 El VPH Sensor Product Piping Product Piping ZMechanical LLD FXIV E] Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD 9VPH Sensor (Piping) 001 El VPH Sensor (Piping) ❑x Sump Sensor 208 ❑ Sump Sensor ❑x VPH Sensor (Sump) 304 ❑ VPH Sensor (Sump) Fill Piping Fill Piping El Sensor (Piping) El VPH Sensor (Piping) NSump Sensor 208 El Sump Sensor ❑x VPH Sensor (Sump) 001 ❑ 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) ID = Identification, SW = Single-Walled, VPH = VacuumlPressureMydrostatc, LLD = line Leak Detector