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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page a of s) Monitorinq Device Used Device Model # Monitoring Device Used Device Model # VENT I TRANSITION SUMP ID : VENT I TRANSITION SUMP ID : ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor ❑ VPH Sensor UDC ID : 1 -2 UDC ID : 31+ ❑ Electronic Sensor ❑ Electronic Sensor ® Mechanical Device FLOATS/ CHAINS ® Mechanical Device FLOATS/ CHAINS ❑ VPH Sensor ❑ VPH Sensor UDC ID : 5-6 UDC ID : _ 7 S _ - - ❑ Electronic Sensor ❑ Electronic Sensor m Mechanical Device FLOATS/ CHAINS ® Mechanical Device FLOATS/ CHAINS ❑ VPH Sensor ❑ VPH Sensor UDC ID : UDC ID : ❑ Electronic Sensor O Electronic Sensor ❑ Mechanical Device ❑ Mechanical Device ❑ VPH Sensor ❑ VPH Sensor UDC ID : UDC ID : ❑ Electronic Sensor ❑ Electronic Sensor ❑ Mechanical Device ❑ Mechanical Device ❑ VPN Sensor ❑ VPH Sensor Other Monitored Component ID: Other Monitored Component ID: ❑ Other (Specify in section Vll.) ❑ Other (Specify in section V1Q Other Monitored Component ID : Other Monitored Component ID : ElOther (Specify in section Vll.) _ ❑ Other (Specify in section VU.) - y Other Monitored Component ID : Other Monitored Component ID : ❑ Other (Specify in section VII.) ❑ Other (Specify in section VII.) Include information for every underground storage tank component monitored by this monitoring system control panel, If the monitoring system control panel monitors more components than this form accommodates additional copies of these pages may be attached. VII . COMMENTS Use this section to provide additional comments about the inventory of the equipment certified. Estops - Tested & Passed . Shear Valves - Tested & Passed . i i i I i f ID = Identification, VPH = Vacuum/Pressure/Hydrostatic, UDC = Under-Dispenser Containment