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MOORE III I al BONN; III ililil!l 1: :::11:1 iii iiiiii I UNDERGROUND STORAGE TANK MONITORING SYSTEM � aftsCERTIFICATInN FORM (Page 2 of 61 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 TLS-350 1329 ,02 Check the appropriate boxes to indicate s eclflc equipment ins ected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : 01 Req TANK ID : 02 Prem LBy tank number, stored product, e (By tank number, stored product, etc. ® In-Tank Gauging (SW Tank) VR 847390-109 ® In-Tank Gauging (SW Tank) VR 847390- 109 ® Annular Space or Vault Sensor VR 794390460 ® Annular Space or Vault Sensor VR 794390460 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ® Electronic LLD VR 8484 ® Electronic LLD VR 8484 ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor VR 794380111,208 ® Sump Sensor VR 794380111,208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor VR 794380-208 ® Sump Sensor VR 794380-208 ❑ 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) I am Monitoring Device Used Device Model # Monitorina Device Used Device Model # TANK ID : 03 Diesel TANK ID : (By tank number, stored product, etc. ) (By tank number, stored product, etc. ® In-Tank Gauging (SW Tank) VR 8473901111109 ❑ In-Tank Gauging (SW Tank) ® Annular Space or Vault Sensor VR 794390460 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ® Electronic LLD VR 8484 ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) m Sump Sensor VR 794380-208 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) i ® Sump Sensor VR 794380111,208 ❑ Sump Sensor 1 ❑ 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 ensor (Sump) ❑ VPH Sensor (Sump) ID = Identification, $W = Single-Walled, VPH = VacuwiVPressumMydrostatic, LLD = Line Leak Detector E :