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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page z of 8) <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 /> VR TLS 350 333. 05 <br /> Check the approopriate boxes to indicate Is ecific a ui ment inspected/serviced. <br /> Monitoring Device Used [ Device Model # Monitoring Device Used Device Model # <br /> TANK ID: 1 - Unleaded TANK ID: 2-Premium <br /> (Y tank number, stored product, etc. ) (By tank number, stored product, etc. ) <br /> ❑ In-Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) <br /> m Annular Space or Vault Sensor VR 794390420 m Annular Space or Vault Sensor VR 794390-420 <br /> ❑ VPH Sensor ❑ VPH Sensor —_- <br /> Product Piping Product Piping <br /> m Mechanical LLD RJ-116-056-5 0 Mechanical LLD LD 2000 <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor VR 794380-208 ® Sump Sensor VR 794380 208 <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) J <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 /> ❑ Sump Sensor ❑ Sump Sensor <br /> F1VPH 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 /> Monitoring Device Usedj Device Model # Monitoring Device Used Device Model # <br /> TANK ID : ; - Diesel TANK ID : <br /> (8y tank number, stored pro ducl, etc. B -tank number,_ stored rop duct, etc.) <br /> ❑ in Tank Gauging (SW Tank) ❑ In-Tank Gauging (SW Tank) <br /> ® Annular Space or Vault Sensor VR 794390-420 ❑ Annular Space or Vault Sensor <br /> El Sensor ❑ VPH Sensor <br /> Product Piping I Product Piping <br /> ® Mechanical LLD RJ-116-056-5 1 ❑ Mechanical LLD _ <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor VR 794380-208 Sump Sensor <br /> r] VPH Sensor (Sump) [I VPH Sensor (Sump) <br /> i Fill Piping Fill Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> E] Sump Sensor El Sump Sensor <br /> s <br /> E] VPH Sensor (Sump) a ❑ <br /> VPH Sensor (Sump) <br /> Vent Piping —M— Vent Piping <br /> ❑ VPH Sensor (Piping) ( ❑ VPH Sensor (Piping) �— <br /> ❑ Sump Sensor ❑ 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-Waled, VPH = Vacuum+PressureMydrostatic, LLD Line Leak Detector <br /> = <br />