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.Apr -.28-03 03:02P Wool v Oil, Inc. 2098 0755 P.01 <br />MUNI RING SYSTEM CER IMATION <br />For Use By All Aa C R MNW the Stare of <br />+ horny Cued- ChgMmr 6. 7, Hdakh nerd Sgl * Code, CJA* tw /Q D— Ammm 3, 7R*23, Ccair$w w Came 1RWktWm <br />This form must be used to doaxww testing and servicing of monitor eQrnpme &for A sraaa�s cr�ti5cation <br />by thrs tecWmnan vvhoor zrx,�,�t mrat�a n k <br />syst�cru owoevivp�asor. Theo Paionns the watt A Dopy of this Them smut be pcoridod to the tank <br />days of Lest deft_ �Opa most anbmit a copy of this fWm to the local agency "Waft USTSYstem within 30 <br />A. Generallnfonnation <br />Facility Name:i�r T,f'� T/�!/� ,xsy <br />Bldg. No.: <br />sift Address, l5 z y r=02r�SN p <br />Facility Comm kte/Person. zip.. <br />' .�21.�- � � / Contact Phone No.: (2 G� ) <br />MaModel of Moni�m8 Syssam; G�- 4-13Ae 6 a <br />- Dale of T4n8/Serr►icing �! / <br />B. Inventary of Equipment TadayCertiBiW <br />OW. L35fG <br />6 PnAw- <br />0 Aniader Spam or Vast Stant. <br />SNOV/ Tei SCUM(). Model: ` 10 U 9 <br />s <br />❑ Hidrotic Lite Lak Detector. Model: <br />i, TWk OverM / HiglrLrevd Swsor. ModeL 'rimes �rr7 <br />❑ Other (spotty !rk! neat t�rpe =ad MW a 80n:tiaa B an Past 2) <br />T,rtt ID: ...._ <br />o I0_71t Probe. Modal <br />0 Annular Space Vwk <br />o S=W // Trench <br />SeniMudd: .__. <br />smm(a). Modell <br />U Fe So" sav=(s), Modd: <br />O U=bW cal Ise L Wk Uaecsar. Mold: <br />❑ EltChOoie Lim teak DckcWr. Yodel: <br />O Tack Overt® / FR& Lord Samr. Irlodet <br />O Other (sporal_yr e24"U t VP and OWN in SOW" 6 an Pane 21 <br />0 0n"=nkW Smsor(s)I Model: <br />O Shear Vatva(s). <br />O Shear Vatve(s)_ <br />Coeraimeat Float(s) and awWsl <br />Dbpasaer <br />W. 3 •y 1 f <br />13 Dispenser Comiarmw sm*s) <br />a shear Vatae(3� <br />T`aat lillr <br />a Ie-7e0t cWi.g Probe. h4odek <br />13 Asanlnr Spa= or Vasa S=W Medd: <br />opoift &MV / Thuch sebs*4 Model <br />D FW Snoop Sesnor(s). Medd <br />a Dine Leak Doloclor_ Modd: <br />O Efeciosie Lae Leat Detector_ Model - <br />'a Tank Ovam / W%k4x d scow. Mode <br />O Otttart-nnand asodd in section E on Paw 2 <br />Tomkl& <br />O 1*-Tw* s t Moder <br />a Alar Sp= or Vmk Sw2w. >ldodet <br />Q Pun swot/ / Theach sc noe(s). Model: <br />O FSI SnW Scwiw(4 Model <br />011/eahaaieat Lac L.ak Det cW- Mod* <br />O hieetreroc Line Lak Lktector_ M <br />O Tisk. Ovwm I IFigk4&,d Season. Modrl <br />Q Outten (y,* oaaip�rat type Bad aaodd in Sectio. E w P4F 2). <br />Dbpo nMr W. <br />OD Wmaser caft"hosix, S"W(s} Model: <br />O Rt� a=t0i=M !NWx) and CZaia(s1 <br />ODisremaer <br />S Yalre(sC S)` Model_ <br />❑Comajameag s and Cbs <br />SID: <br />show Vadvo(t7otest Seasor(s� Hfodol: <br />'If the.hCr Sorlfwns nrorC laaJrs a - I I • 0 Disperse,- � Fps) and GZwn(s� <br />copy tors Hasa [acdrrdc a>Formataon for ear task and dmpeww at tie tfdt ty_ <br />C. Certification - I eft ttb diu.t the ejsipowm id.ntHW L this dacwsert ww <br />tuk%dma. Attacied to tall ,Oert!!�a is jn*xv alias i > dvoe wilt tis , <br />correct asd a Plat Plat aMwi� tis ta�atet ad ( ciaeirliat:) aaaaQar� w verifj tits iafarnatiw is <br />�� °i4�a. Fir' airy <br />atlad ad a nslwrt; l stink adf iobr - of raparts. I tie am <br />a!!�(M1- Q S�Sber aaNrP <br />Teclmic'2n Name (priotk Bruc <br />Cextifntor► No.: License. No_: 805 705 <br />T* ting Company Maw: TechIand Testing, Inc. <br />Phare No_:� © 7 ti 5' �/ �2_ C) <br />SiftAddtzss: 3515 A. Hardf3tand Ave. Atwater, <br />. Dace of Tvicing 44 .1 •2-/ 0 -:7, <br />Monitoring System Certl&stion Paha 1 of 03/01 <br />