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FEB-02-2005 15:47 SERVICE STATION SYSTEM 408 971 0135 P.02 <br /> rtes-nt-�nno 1Lt :O6 RM IS 916 25 2003 P. 01 <br /> KEH-BI-SBS 19:17 �'*WICE STATION SYSTEM 1.01 406 W1 0135 P.21 e <br /> Monitoring System Equipment Certification 1 <br /> CIO <br /> For Un By All JurGdtetlow R'lthin 2Yw State olCalybmia <br /> Author*G7ted: Cbnpfer 6.X Ffeahh and Suety Code;Chnpur 16,DA*fon 3, 77da 23, Calitamia Code of Reguladow <br /> This fbrm muSt be used to dncumeut testing and sesvlcing of nwitorin6 equipment.A aeoU&certificaliu or row must be <br /> R=ared ibr m_h ma=tonna Mrem cnntrtt,Lpaa J.by the ttchwemn wlm pecthcpls the W"k.A copy of 1114 fits=must be provided <br /> m the tank system owner/opcWor. The owns/opmwor wmat submit u copy of this tom to the local agency mgttldting UST system <br /> within 30 days of test dram <br /> A.'General Informatio4 <br /> PSdtity Name:Saf nww 01760 Bldg.No.: <br /> Site Addtese: 2008 Cougft Chub DW.a Delano Ave City: Stocleon, CA Zip: 86204- <br /> Facilitycomactperson;&61/ WAJ Contact Phone No.:f206)461.6645 <br /> Make/SMlodd of bed"System:VIR TLS•36n Dedu of Teaduamcmcdeg; 111 <br /> B. TaventoryofEquipttlentTeded/C:erd&ed i/2-7 � <br /> CMk Iba aeproPrhM heti=MLo4Mab ryrtlNe egak)ameta..peabdlanlard: <br /> T k1D• ID w <br /> (�-7 <br /> AS a• d t -iae'kT,mr6 0 .• . <br /> A=RTIAr Spw or Vault Simon mo":-i-79 Y C- 'moi Amends gym of VAUR Sensor. NW*I, T 0- <br /> PI ata er=rs\Ttedfdl Sa (k} NIO&L• ��I - v��3d p. Sump%TwuA samat(a). MWd: y - <br /> IllSar senmr(r} Weal: 7 pa?. $argp$aamr(1} Nbdol: <br /> IUmlWkna-M+•. +7 ou 7 micamlml liN I^kUa=me. yljger 7 <br /> n a • <br /> elo llrte Leak Deaths. Medd:�77,7 Llm t.aa►I)rbiaor: M7dol: + as <br /> M-rink ovadu%Afebl.rai itamor. Modde s±➢ Dip 0-/iakOwl'9dt laghxoud saki= h6m +a2glw <br /> --•3= q (oa �i0a yams mp wa <br /> Tame ID: Tack ID• <br /> R'Y- sna=g Q In- sag=aPwG& <br /> p//Ckdar Beaux or VaWiaamor. DdodoL• T )AY.34a__.. 14._ p aenul.r apse exvadr senor. Modat� 7 ! <br /> p tY�iag swro l"fmmhSkanr(r} NL"i 7 9•'�j 5'D-�t=S 4 �P�nSaump�Trmoh 9anwr G} Nladdl 7 - - <br /> lSraripSunxrr(r} Mode 4 79Ytw•-•s04es p Fal Sun Senwr(s1 LeotW: T <br /> p Lrorhatdnl lAra t.okl)owaar• N6dLL"7 (3 Uodunlmt Lim t. kl)vlwkx, Nbdd! 7 <br /> m roammoblAmlokDWA . Ldkdd: 7 rro (3 Fianna Uwlnakl)ebotcr. Modell 7 <br /> it"ovum l HiSb•Uwl Saanr. N(edd: 7Q_&g w <br /> p Unk oAal t uig,) l ewl a0e.or• MW <br /> a : 7 <br /> 13 0dwr(ID1WV kquOrmat typo add Medal la am nd Fabc 4 agm(y,wlty onulpmaat pipe aced ewdel rn swtlau E on rase x). <br /> IDs 01 DUvower ID: <br /> egwrCoawnmam 7alnr . <br /> shay vrlw(.} hearvalk(x} <br /> t) M+vaaam'CadlklrnnmaPiear<q.adclmin(aI• D Dialfewcnnudnmwdpla.l(.)andChuSnG} <br /> G em®r r ■ e 'tyrss.rC aJ, ..7yrZ <br /> VawG> Im..•va7eW <br /> p DiRw++wCaatt(ameaaPlat(a)Wt"reia<•3 Q D:apeemrcooWmmtPlaat(O.nd ch.tu(r} <br /> n, ewer Dispense•IDl <br /> marCawsoiNOE. rel awrcae .er . M <br /> p wrVdw(a} V"(11 <br /> G Alpomor C.awme.ar rlo.tG)aadc�+G> p tdapunam CvnWumreFbat(,)anti CNdn(.} <br /> •ffibe 4elBy aonaaAm more ordipenam.mpy del.. amdoa tet awry uNk and dl�egttl at as fadilly <br /> C. CefBffealten- I certify tMt tie qummm�ikl7d4dad cep der eneua»at ray empeeroNstrvkae b awotdeeoe trdh tYe + <br /> akaabOwer4l(Wdslft. Alftdmd lo On Carneeaa.ab iOrmamtlkp G¢nmaufa nms•eamkihb)rarrary m w1lf7 dmt this <br /> lohsaktke b aamot wrf a rb{I'ba tll►wlat ttr hytartaf nmatkthra esVIVINI e. Per way atpdpmkmmpabk of etamdag.seh <br /> npa.a,teaw obaaWeheda aiarNopped� p 8y.bm.aoap (y/A/lYmhb/bry,'�putt_//// <br /> Technician Nemo(print} S-RmndyW SigoeWrO: w �- ---� <br /> cauncadauNw Licrose.Am 468184 <br /> TatW Company Name Ur.04.Sys. -- Phone No.: (408)674.2445 <br /> Site Addtws: 2808 Country Club DhPd. Delano Ave Dato of Teatiaa avicing,3639MSr <br /> kh'?4,7 <br /> 1 <br />