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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) <br /> VI. INVENTORY OF EQUIPMENT CERTIFIED <br /> A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. <br /> Make of Monitoring System Control Panel Model of Monitoring System Control Panel Software Version Installed <br /> GILBARCO ::11 E M C 329 . 01 <br /> Check thea ro riate boxes to indicatespecific equipment ins ected/serviced. <br /> Monitoring Device Used Device Model# Monitorin Device Used Device Model# <br /> TANK ID: 87 OCTANE TANK ID: 89 OCTANE <br /> (By tank number, stored product,e (By tank number,stored product, etc. <br /> 0 In-Tank Gauging (SW Tank) M A G 2 0 In-Tank Gauging (SW Tank) M A G 2 <br /> 0 Annular Space or Vault Sensor 4 2 0 0 Annular Space or Vault Sensor 4 2 0 <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> 0 Mechanical LLD 99 LD 2000 Z Mechanical LLD 99 LD 2000 <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> 0 Sump Sensor 2 0 5 ❑x Sump Sensor 2 0 5 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> A Sump Sensor 2 0 5 ❑x Sump Sensor 2 0 5 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑x Sump Sensor 2 0 5 ❑x Sump Sensor 2 0 5 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Monitoring Device Used Device Model# Monitoring Device Used Device Model# <br /> TANK ID: TANK ID: 91 OCTANE <br /> (By tank number, stored product,etc.) (By tank number,stored product, etc. <br /> ❑ In-Tank Gauging (SW Tank) ❑x In-Tank Gauging (SW Tank) M A G 2 <br /> ❑Annular Space or Vault Sensor ❑x Annular Space or Vault Sensor SHARED W/ 89 OCT <br /> ❑VPH Sensor ❑VPH Sensor <br /> Product Piping Product Piping <br /> ❑Mechanical LLD x❑Mechanical LLD 99 LD 2000 <br /> ❑ Electronic LLD ❑ Electronic LLD <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑x Sump Sensor 2 0 5 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Fill Piping Fill Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑Sump Sensor <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vent Piping Vent Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑x Sump Sensor 2 0 5 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> Vapor Recovery Piping Vapor Recovery Piping <br /> ❑VPH Sensor(Piping) ❑VPH Sensor(Piping) <br /> ❑Sump Sensor ❑x Sump Sensor 2 0 5 <br /> ❑VPH Sensor(Sump) ❑VPH Sensor(Sump) <br /> ID=Identification,SW=Single-Walled,VPH=Vacuum/Pressure/Hydrostatic,LLD=Line Leak Detector <br />