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Underground Storage Tank <br />Monitoring System Certification Form <br />Tank ID: <br />Sensor ID <br />Sensor Model <br />Component(s) Monitored <br />Pass <br />Fail <br />1/2 <br />float and chain <br />1/2 <br />❑ <br />❑ <br />3/4 <br />float and chain <br />3/4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />U DCs: <br />Sensor ID <br />Sensor Model <br />Component(s) Monitored <br />Pass <br />Fail <br />1/2 <br />float and chain <br />1/2 <br />® <br />❑ <br />3/4 <br />float and chain <br />3/4 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Describe all answers marked "No" or "Fail" and proposed remedy in Section 9. <br />List all Monitoring equipment either replaced or repaired in Section 9. <br />Page 5 of 9 <br />