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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 350 329 . 01 Check the appropriate boxes to indicatespecific equipment ins ected/serviced. Monitoring Device Used Device Model # Monitorin Device Used Device Model # TANK ID : 87 TANK ID : 91 (By tank number, stored product, e (By tank number, stored product, etc. ❑x In-Tank Gauging (SW Tank) MAG-1 Z In-Tank Gauging (SW Tank) MAG-1 ❑x Annular Space or Vault Sensor 409 0 Annular Space or Vault Sensor 409 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping Z Mechanical LLD 99 LD 2000 ❑x Mechanical LLD 99 LD 2000 ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 208 ❑x Sump Sensor . 208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑x Sump Sensor 208 0 Sump Sensor 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 # Monitorin Device Used Device Model # TANK ID : DIESEL TANK I ° : DIESEL EAST B tank number, stored product, etc. 8 tank number, stored product, etc. ❑x In-Tank Gauging (SW Tank) MAG-1 ❑x In-Tank Gauging (SW Tank) MAG-1 ❑x Annular Space or Vault Sensor 409 Annular Space or Vault Sensor 409 E El VPH Sensor ElVPH Sensor Product Piping Product Piping ZMechanical LLD LD 3000 ZMechanical LLD LD3000 ❑ Electronic LLD ❑ Electronic LLD El Sensor (Piping) El VPH Sensor (Piping) x❑ Sump Sensor 208 Z Sump Sensor 208 El VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping El Sensor ( Piping) El VPH Sensor (Piping) ❑x Sump Sensor 208 ❑x Sump Sensor 208 El Sensor (Sump) ❑ VPH Sensor (Sump) Vent Piping Vent Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) i ❑ Sump Sensor ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Vapor Recovery Piping Vapor Recovery Piping El Sensor (Piping) El VPH Sensor (Piping) ❑ Sump Sensor [:1 Sump Sensor If= VIROI ��IENI I E El VPH Sensor (Sump) El VPH Sensor (Sump) I P ID = Idenfification, SW = Single-Walled, VPH = VacuumlPressureftdrostafic, LLD = Line Leak Detector