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f 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 & Ronan Engineering TLS-350 & X76S 329 . 01 Check the appropriate boxes to indicate specific equipment inspected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank ID : T-1 Diesel Tank ID : T-2 87 (By tank number, stored product, etc.) (By tank number, stored product, eta E In-tank Gauging (SW Tank) VR- Mag - 1 E In-tank Gauging (SW Tank) VR -Mag - 1 E Annular Space or Vault Sensor VR-302 E Annular Space or Vault Sensor VR-302 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping E Mechanical LLD VMI -LD-2000 E Mechanical LLD VMI - LD -2000 ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) E Sump Sensor VR-208 E Sump Sensor VR -208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ 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) Monitoring Device Used Device Model # Monitoring Device Used Device Model # Tank ID : T-3 91 Tank ID : T-4 Waste Oil By tank number, stored product, etc. (By tank number, stored product, etc. E In-tank Gauging (SW Tank) VR- Mag - 1 ❑ In-tank Gauging (SW Tank) E Annular Space or Vault Sensor VR-302 E Annular Space or Vault Sensor LS - 10 El Sensor [:1 VPH Sensor Product Piping Product Piping E Mechanical LLD VMI - LD-2000 ❑ Mechanical LLD I ❑ Electronic LLD ❑ Electronic LLD € ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) F E Sump Sensor VR-208 E Sump Sensor LS -3 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ 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 = VacuumlPressure/Hydrostatic, LLD = Line leak detector