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W..rl, float• 2267585
<br />MONITORING SYSTEM CER JFICAT10N
<br />Pur U.ve $y �Jll Jur ixrlirtivur Within the Starer Califorexia
<br />AjIrhoritt" Citerl: i 'hrrf,fe•+" h.i . Hemlith vnd &fl/ L• C.'ade: C-'trufmcr 16..Drvisiorr L Title 23. Cedl frtr tkt Coe It• r) ?egWre:i•7+:+
<br />Pi:_ i_ 1:,nn musT be Lard La dnC"un1CM testing rued servicing of moidwring egttiprnam, seoaiatu gcgi!iCNtiot_i nr
<br />i(r_it_�r(triUrHl'i.sVSlct?),copi!'ol_miriel by rhe lcclmicivil w110 Ilurrol-MS L11C Rork. ca1)v u Iltis Font must bi; pravidid IL7 I 12 a ti:
<br />utt•nm,•rA:peratIli'. The nu'RCmlpp.^l'7101' mpsl Submit :; c(II)y Df Mis form to th local agency rquilaliny UST sysrcros u•irhi:: t)
<br />General l(i{y'1'�`�for•i3lalih t�
<br />i'.!ti!lh'.. Nanic': '� �. �1 lM
<br />1cc ;rens: t�g$ l% rk t j' r.7 City:
<br />i ;iiii!v C-omacr I'rrsan: � _.. -� Coni ct Phaile No.: i.__....�.-�)... _..-_-•-- --•-•--._._ ..
<br />,lckz/:Vlodcl nh3+lanitrnilr•; SY.Sret»' .'-[�_--------___-_- Dar: of'c.eting/Srrt•iri»g: 4g
<br />>. 1riventot'' of Equipment Tested/Cee'tified
<br />htex Ole Lure. eriste s to ittt,ICme apecific epuipinrtlt IsKU1 CID!Vscrri[rd:
<br />• •— ...�_._...•... :,uxr...�.. �- '•-r�rs��a�„n,}.am_ -r -r.•assar:-: .. �. �
<br />Tank ED;.. _._ ._._.....
<br />in Pani t.i: ❑ging 1'robt:. Model: i��... _ R frt-7"«'nk Gau�i g Probe. AdodcL '
<br />•.J -,nuulnr.tipaCc or +.lulr Ccnu,r. MDdcl: 0 Annular Space r VauIL SerkRlr_ Model:--_-
<br />_? i'i1)imtg Sump: Trunch 1cncDrrsl_ NI Cl del: . � - _ - Q Pipi,lg Suntp J rcnch Semtmisl. mode?: _--...-------- ..............
<br />rill Sump Scnsorls>. Modell: ❑ fill Sump Sen r(s), Model: T_-,_ .-_-•_•_-_•__ 3
<br />J .'.Iccitani�:a Linc leak I.)CWC101'. Mudd: -J O Meehanisul J,ir e Leak Demilor. Model: -_-----•—_--,-
<br />c i iiicci.onic Linc E.cak Detector. model: _ ❑ Mcctronic Liix Leak Detector. Mode l:
<br />,l '1';tnk C):Lr(ili; 1•(iLil•1.4ve1 $cnsor Model: _ Q Tank C)verlill I High -Level Sensor. Ma�'cJ:
<br />e
<br />f;lht r (stnceii' a ali':ntcn, tyle unci rnuJel ill SCeliDn 1: oil Page 71 Cl ClthCr (s ccir ul ,rtcnt L c �nJ tltpdul in Scclion ti Oil Pu�c 1). f
<br />CAL
<br />.l.-! Li st Ci:t�:::ln Jtrcll, _ _ lPdln,IT1. _--�_- J In-Tatlk Ga.•gi Probe Mfourl - -- •-•51
<br />Anitr'!: Space c:r V::+liJ t,ur. tvlodct ❑ Titular Sllacc r Vault Selsp; JrluJcl: .._ _.. k
<br />P11�Lotlt Sump; 'I'rerlrit SCnsD:(d- MUd1!1 - r -_—... ❑ Pipin•, Sump ! 'rcnch Sr:.nKor(5)- lblodrl: • ..._._......-- _-• e
<br />FIE SIM113 SLAIM1115J. ❑ bill Snnip Sens r(s;, h+lodcl: . _._— _ ..._...
<br />!,Itchunic;,!. I.:IIe I.cok DOCCuni. Model: ❑ Mccltantcal Lim leak Detector. Mocci: •_-_•- •., _. _ .__..._
<br />larcrvnrc Lcir :.aak l)cicunr. Modc1. _ �- --. ❑ Llectronic Linc Unk Derector. IVIC1 tell:
<br />J *;,umk Ovctrl( i I•ti:.11-1.1;V0 Scnsnr. model: _ Q T;; ilk OverfiI l 14 igh-).c+'cl Scrrsor. ic9odcl:
<br />011Ct l• (-�ilfy equ�lncm iype:stet wodcl in Section G o+tpa,.e 2). �0 0nccr(s eeiry 4 q U mcrl ty 0, id model in Seed on P on Pale
<br />?l:I;;w:tser ID: DisEre,t.er 10: �•....--,-- .. _... .. -- __
<br />ipipcilsL;i (:a,11LIb t:,•ni Sensurts). Modc1:0 Dispci)sa Con inmcnt Scnrsar{s). oriel:..._._.._..... ---- ••- 1
<br />! >hc.! r V;ti•rc{51. ❑ Shear Valve(S) _
<br />i :lisp,:;ttirr t:or:I::i:u^lent i'lual(xl anJ C'.huin(s)•� -�� ❑ Dis mser Cont innvil(Flow-t(s) Lund (atein(s:.
<br />i);Spcuser il): __ Dispenser ID: _.._. -. -_ ....
<br />17ispuuscr{;onfairmrntSensorls'r. MoJcl: —_. ❑ DispcnsCrCon inmcntSensoi(s). 1Ao[icl:
<br />Si1c :r L';:Ivry--)-
<br />D Shear Varvc(s)•
<br />? i•)%Spenser C(InlLihimCnl I-1u;tc(sl and Ch;+in(s).C� DispcnScrCon inmtnt m=loatts) anti Ch:tin(s):.,....-
<br />iyis;x•rtsct' I I): _ _ _ _ Dispenser ID:
<br />i� i lisprnsrr Cauninmenl Sensor( ,. .'tEDdol: W Q Dispenser Cont inmcnt Sensor(s). Monet:
<br />"hear Valvcfs)- 0 5ltcat Valve{s). V
<br />LlI):Si)enscr C-ulltmiIIrm:III Fla aI(s) tinct CMin(s). - _ 0 pts enserCont inment f loat(s) and Chain(s).
<br />'yll•i0C t,c`HLV :antaips inure WAS urJispcnjCts, copy [165.form. include laromtation for e�
<br />f:cr tific.ttion 1 mvriI'v [flat file cclaitlmcni i(Mli inecr in this (lottilnc,tt wax i,ls
<br />r+u'r+laliucs. :vtachtJ fu (Iris {'crliiieafio:t is info nim f)ert (e.g. Ilaoolacturcrs' c',
<br />cn,-recr :Lad a Pk,t PI:u1 satou'in. tlLC layupf all' Luouitoring c ui oleut. For any et u
<br />an:,eked Crean• rif rhe re nrr, (r ec-k 1W that 0,0140): rtSystctil set-up
<br />.,.:nt.:•.•�:, \'a,;lc fllrinl): S —•------'•.-- Siguarurc=....
<br />:.,!:.••Tinct \ln.:3b�_ _ License. Nu.:
<br />.,_• .. .ter ......_
<br />llagL 1 col' 1
<br />•'tIntiror•iuk :SrcferTm C'c, (it'll, Dillon
<br />tank and d(spcnscr at rhe Pacil i1•.
<br />,-W-icrv(ced in itcai-Mmicc witll Vic rnanufaettlrers-
<br />dists) mxcss:Iry to rt:rifl' Chill this information i,
<br />Lcttf caprabJr nrgencralitt Fsuch repo ris, I h:t+•c -IIw
<br />�tla..hist y repu�
<br />flarenf I_Mi lr(R/SCTVICill'
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<br />Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759
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