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10 iiiiiii IN <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM ( Page 3 of 6) <br /> Monitoring Device Used Device Model # Monitoring Device Used Device Model # <br /> VENT ! TRANSITION SUMP ID : VENT t TRANSITION SUMP ID: <br /> [:] Sump Sensor ❑ Sump Sensor <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> UDC ID : 01 -02 UDC ID : 03-04 <br /> ® Electronic Sensor VR 794380-208 ® Electronic Sensor VR 794380-208 <br /> ❑ Mechanical Device ❑ Mechanical Device <br /> ❑ VPN Sensor ❑ VPH Sensor <br /> UDC ID : 05-06 UDC ID : 07-08 <br /> ® Electronic Sensor VR 794380-208 ® Electronic Sensor VR 794380-208 <br /> ❑ Mechanical Device ❑ Mechanical Device <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> UDC ID : 09- 10 UDC ID : 11 -12 <br /> ® Electronic Sensor VR 794380-208 ® Electronic Sensor VR 794380 -208 <br /> ❑ Mechanical Device ❑ Mechanical Device <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> UDC ID : 13- 14 UDC ID : 15- 16 _ <br /> ® Electronic Sensor VR 794380-208 ® Electronic Sensor VR 794380-208 <br /> ❑ Mechanical Device ❑ Mechanical Device <br /> ❑ VPH Sensor ❑ VPH Sensor <br /> Other Monitored Component ID: Other Monitored Component ID : <br /> ❑ Other (Specify in section VII.) ❑ Other (Specify in section VII,) <br /> Other Monitored Component ID : Other Monitored Component ID : <br /> ❑ Other (Specify in section Vil.) ❑ Other (Specify in section Vll.) <br /> Other Monitored Component ID: Other Monitored Component ID: <br /> ❑ Other (Specify in section Vll.) ❑ Other (Specify in section VII) <br /> Include information for every underground storage tank component monitored by this monitoring system control panel. If the monitoring system <br /> control panel monitors more components than this form accommodates, additional copies of these pages maybe attached. <br /> VII . COMMENTS <br /> Use this section to provide additional comments about the inventory of the equipment certified. <br /> Shear Valves - Tested & Passed <br /> E-stop - Tested & Passed <br /> i <br /> E <br /> E <br /> i <br /> ID = Identification, VPH = Vacu=Rressura Horostatic, UDC = Under-Dispenser Containment <br /> i <br />'r <br /> I, <br />