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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 3 of 6) Monitoring Device Used Device Model # Monitoring Device Used Device Model # VENT / TRANSITION SUMP ID : TRANSITION SUMP VENT / TRANSITION SUMP ID : ❑ Sump Sensor 208 ❑ Sump Sensor ❑ VPH Sensor ❑ VPH Sensor UDC ID : 1 -2 UDC ID : 34 E Electronic Sensor 20 $ ❑x Electronic Sensor 20 $ ❑ Mechanical Device ❑ Mechanical Device ❑ VPH Sensor LEI VPH Sensor UDC ID : 5-6 UDC ID : 7-SAT 7-8 E Electronic Sensor 20 $ 0 Electronic Sensor 208 ❑ Mechanical Device ❑ Mechanical Device ❑ VPH Sensor ❑ VPH Sensor UDC ID : &9 SAT 9- 10 UDC ID : 10 SAT E Electronic Sensor 208 E Electronic Sensor 208 ❑ Mechanical Device ❑ Mechanical Device ❑ VPH Sensor ❑ VPH Sensor . UDC ID : 11 SAT UDC ID : 11 -12 E Electronic Sensor 20 $ E Electronic Sensor 20 $ ❑ Mechanical Device ❑ Mechanical Device ❑ VPH Sensor ❑ VPH Sensor Other Monitored Component ID : 12-13 SAT Other Monitored Component ID : 13-14 ❑x Other (Specify in section Vll.) 208 X Other (Specify in section VII) 208 Other Monitored Component ID : 14 -SAT Other Monitored Component ID : x❑ Other (Specify in section VII.) 20 $ ❑ Other (Specify in section Vll.) Other Monitored Component ID : Other Monitored Component ID : E] Other (Specify in section Vll.) El Other (Specify in section Vll.) 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. i I I i z ID = Identification, VPH = Vacuum/Pressure/Hydrostatic, UDC = Under-Dispenser Containment SII