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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page 2 of 6) VI. INVENTORY OF EQUIPMENT CERTIFIED ID = Identification, SW= Single -Walled, VPH = Vacuum/Pressure/H A separate Monitoring System Certification Form must be prepared for each monitoring system control panel. Make of Monitoring System Control Panel Gilbarco Veeder Root Model of Monitoring System Control Panel TLS 350 Software Version Installed 120.02 Check thea ronate boxes to indicatespecific equipment ins ected/serviced. Monitoring Device Used Device Model # Monitorina Device Used Device Model # TANK ID: B . tank number, stored roduct, etcUnleaded t4 In -Tank Gauging (SW Tank) PA2650960200 TANK ID: 8 tank number, stored product, etc. Diesel W In -Tank Gauging (SW Tank) 847390-107 ® Annular Space or Vault Sensor 794390420 ® Annular Space or Vault Sensor 794390-420 ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) R Sump Sensor 794380-208 ®Sump Sensor 794380-208 ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ 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: Waste Oil (By tank number, stored product, etcj ❑ In -Tank Gauging (SW Tank) TANK ID: (By tank number, stored product, etc. ❑ In -Tank Gauging (SW Tank) ® Annular Space or Vault Sensor 794390420 ❑ Annular Space or Vault Sensor ❑ VPH Sensor ❑ VPH Sensor Product Piping Product Piping ❑ Mechanical LLD ❑ Mechanical LLD ❑ Electronic LLD ❑ Electronic LLD ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ® Sump Sensor 794380-208 ❑ Sump Sensor ❑ VPH Sensor (Sump) ❑ VPH Sensor (Sump) Fill Piping Fill Piping ❑ VPH Sensor (Piping) ❑ VPH Sensor (Piping) ❑ Sump Sensor ❑ Sump Sensor ❑ 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) ydrostatic, LLD =Line Leak Detector