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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 /> Gilbarco EMC 122 . 00 <br /> Check the appTpriate boxes to indicatespecific equipment ins ectedJserviced. <br /> Monitorinq Device Used I Device Model # �� Monitorin Device Used I Device Model # <br /> TANK ID ; 1 - Unleaded TANK ID : 2-Premium <br /> jey tank number, stored product, etc.) (By tank number, storedroduct, etc. <br /> 0 In-Tank Gauging (SW Tank) 0 In-Tank Gauging (SW Tank) <br /> Annular Space or Vault Sensor VR 794390-409 0 Annular Space or Vault Sensor VR 794390-409 <br /> 0 VPH Sensor 0 VPH Sensor <br /> Product Piping Product Piping <br /> 0 Mechanical LLD VMI LD2000 0 Mechanical LLD LD2000 <br /> 0 Electronic LLD 0 Electronic LLD <br /> 0 VPH Sensor (Piping) O VPH Sensor (Piping) <br /> 0 Sump Sensor VR 794380-208 0 Sump Sensor VR 794390-205 <br /> 0 VPH Sensor (Sump) 0 VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> 0 VPH Sensor ( Piping) ❑ VPH Sensor (Piping) <br /> 0 Sump Sensor VR 794380-208 0 Sump Sensor VR 794380-208 <br /> 0 VPH Sensor (Sump) 0 VPH Sensor (Sump) <br /> Vent Piping Vent Piping <br /> 0 VPH Sensor (Piping) ❑ VPH Sensor (Piping) <br /> 0 Sump Sensor 0 Sump Sensor <br /> 0 VPH Sensor (Sump) 0 VPH Sensor (Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> 0 VPH Sensor (Piping) 0 VPH Sensor (Piping) <br /> 0 Sump Sensor ❑ Sump Sensor <br /> 0 VPH Sensor (Sump) ❑ VPH Sensor (Sump) <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> TANK ID : TANK ID : <br /> (By tank number, stored product, etc)-Diesel By tank number, stored product, etc.) <br /> 0 In-Tank Gauging (SW Tank) 0 In-Tank Gauging (SW Tank) <br /> 0 Annular Space or Vault Sensor VR 794390-409 0 Annular Space or Vault Sensor <br /> 0 VPH Sensor ❑ VPH Sensor <br /> Product Piping Product Piping <br /> 0 Mechanical LLD LD2000 0 Mechanical LLD <br /> 0 Electronic LLD ❑ Electronic LLD <br /> 0 VPH Sensor ( Piping) 0 VPH Sensor (Piping) <br /> 0 Sump Sensor VR 794380-208 0 Sump Sensor <br /> 0 VPH Sensor (Sump) 0 VPH Sensor (Sump) <br /> Fill Piping Fill Piping <br /> [IVPH Sensor (Piping) 0 VPH Sensor (Piping) <br /> 0 Sump Sensor VR 794380-208 0 Sump Sensor <br /> 0 VPH Sensor (Sump} El VPH Sensor (Sump) <br /> Vent Piping Vent Piping <br /> 0 VPH Sensor ( iping) ❑ VPH Sensor (Piping) <br /> ❑ Sump Sensor ❑ Sump Sensor <br /> 0 VPH Sensor (Sump) 0 VPH Sensor (Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑ VPH Sensor (Piping) 0 VPN Sensor (Piping) <br /> 0 Sump Sensor 0 Sump Sensor <br /> 0 VPH Sensor (Sump) <br /> El VPH Sensor (Sump) <br /> ID = Identification, SW = Single-Waled, VPH = Vaa arrWressure"drostafic, LLD = Line Leak Detector <br /> Y <br />