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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 TLS -350 333 . 05 Check the appropriate boxes to indicatespecific equipment ins ected/serviced. Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : T -1 87 20K Gallons TANK ID : T -2 87 20K Gallons 8 tank number, storedproduct, e (By tank number, stored product, etc. ❑ In-Tank Gauging (SW Tank) 846390- 109 ❑ In-Tank Gauging (SW Tank) 846390 - 109 Z Annular Space or vault Sensor 794380- 302 ❑x Annular Space or vault Sensor 794380 -302 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑x Mechanical LLD VMI LD 3000 ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor ( Piping ) ❑ VPH Sensor ( Piping) x❑ Sump Sensor 794380-208 Z Sump Sensor 794380 -208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor ( Piping ) ❑ VPH Sensor (Piping) [] Sump Sensor 794380 -208 0 Sump Sensor 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) Monitoring Device Used Device Model # Monitoring Device Used Device Model # TANK ID : T -3 87 20K Gallons TANK ID : T -4 87 20K Gallons 8 tank number, storedproduct, e (By tank number, stored product, etc. ❑ In-Tank Gauging (SW Tank) 846390 - 109 ❑ In-Tank Gauging (SW Tank) 846390 - 109 N Annular Space or vault Sensor 794380- 302 0 Annular Space or vault Sensor 794380 -302 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑Q Mechanical LLD FE - Petro STP MLD - HC ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor ( Piping ) ❑ VPH Sensor ( Piping) Z Sump Sensor 794380-208 Z Sump Sensor 794380 -208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor ( Piping ) ❑ VPH Sensor ( Piping) Z Sump Sensor 794380 -208 0 Sump Sensor 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 El VPH Sensor (SUMP) ElVPH Sensor (Sump) ID = Identification, SW = Single-Walled, VPH = Vacuum/PressumMydrostatic, LLD = Line Leak Detector