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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) <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 /> Veeder Root TLS-350 334 . 00 <br /> Check the appropriate boxes to indicate specific a ui ment Inspected/serviced. <br /> Monitoring Device Used I Device Model # Monitortn Device Used I Device Model # <br /> Tank ID: T1 : 87 Slave Tank iD: T2 . 87 Master <br /> (By tank number, storedno uct etc. B tank number stored product, etc. <br /> ❑ In-tank Gauging (SW Tank) ❑ In•tank Gauging (SW Tank) <br /> ® Annular Space or Vault Sensor 794390409 ® Annular Space or Vault Sensor 794390409 <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Pi in <br /> ❑ Mechanical LLD ❑ Mechanical LLD <br /> ❑ Electronic LLD ® Electronic LLD 8484 <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor 794380-208 ® Sump sensor 794380-208 <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump Sensor 794380-208 ® Sump sensor 794380-208 <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 /> ❑ 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 /> monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> Tank ID: T3 : Diesel Tank We T4: 91 <br /> (By tank number, stored product etcJ (By tank number stored product, etc. <br /> i <br /> ❑ In-tank Gauging (SW Tank) ❑ In-tank Gauging (SW Tank) <br /> k <br /> ® Annular Space or Vault Sensor 794390409 ® Annular Space or Vault Sensor 794390409 <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> ® Mechanical LLD VMI 991.D-2000 ❑ Mechanical LLD <br /> ❑ Electronic LLD ® Electronic LLD 8484 <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump sensor 794380-208 ® Sump sensor 794380-208 <br /> [:1VPH Sensor (Sump) El VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ® Sump sensor 794380-208 ® Sump sensor 794380-208 <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 /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Va or Recovery Piping Va or RecovanAPi in <br /> ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> In a kiartifirafiN, SIN a !SimkawaiWrl VPH c Varj v cnV w w irPMvr rrvda%n i i n o i im kak riolorinr <br />