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f`YilIdDL^�9'�'1Glla�l�llJ <br /> /.ie, f',rr 81'-IU 111,1 rlirlions If Will?dlr %teda' li(Calif,/oll'r <br /> ,I urhul'%rn C'ilerl:['ln/pn:r GJ, llrulll)nu�l.Y.(fr{r('nrG:; ('llrrplel 16, 1)ivi.rinIJ. '/ride_J, r'nllfi,nli,I i'udr of Krq I11lti/uav <br /> Thi:; liu'nl nuett be used to (lucunlent leslitu„ wld serviciu , of nwlliloring equiplucof. A sel2(irae Certilic:lliun a' rcl?q[!, jjusI he <br /> prc rrl lin eachmonitorin_"tivs !!i conh'ul p;lgel by the luchnici:u,who perrurms:file work, A copy of llliS titan n)usl he provided it, <br /> the tank system owner/opunflur. The ovvnel/upemtor must submit a copy o1'tlris form to the lural agerwy regulating US'I sy.stams <br /> within 30 days uriest dale. <br /> A. (:(+ucrnl lnforin:)tion i Bldg. No.: <br /> Facility Nave: 'f ._. .. t,1----'- ...._ <br /> ../ J .�r .._• .. City. i�.. . . zip; <br /> SilcAddress: .'. 1 �'— -- <br /> 5 / <br /> Facilily Canlnct Person:�. ` �. Contact 1 Inn•Nu.:( Z�-'f..) �. _f'IJ - _ <br /> Make/Model ol'Moniloring Syslou: Dale cf'rusling/Servicing: i,Z`_A_•" /rte% <br /> I;, Inventory of lequipnlent'1'ested/Certified <br /> (11cru file N 1pen mi+111•INI]CS Ito IIn14 Ate ti win . ui n,rnt ills low t.1 SUIT-Ial: <br /> Tau1r 1U'.S-L �— ..— ..- -.Model: — <br /> ,Ql lu-Lurk Guugiug l'mhe. Model:_ .�� P'In=funk tlaugiug l'i(dx. MoA1a:_ MI�.G...-, <br /> LJ'A umlar Spuce or Vault,Senor. _L).-n 0 Annular Space or Vault Sensm', Model: <br /> J-d Piping Sump/Tr"C"Sensnr(s). Model; _.. UL`J d 1'ipiug Sump/Trench Sensul W. MOLM: <br /> U pill Sunip Sensor(s), Model: ._ ., <br /> U Pill Sump Sen,sar(s). Mndel: _ _---_' ) y I + „ — <br /> ld Mechuuicul Line Leuk Detector. Model; L_\7 7�r V4:_—. . UJ?j Meclmnicul Line Leak Ietec or. Model: 1- r:,— — <br /> U Lleutrnnic Line Leak Detector. Madel:_ <br /> U tlecb'nnic Linc Lenk Detector. Model:_ _ —. C3 Turk Overfill/tligh-Level Sensor. Mudcl; <br /> U 'I'uuk Overfill/High-Leval Sensor. M1Klul: .. <br /> U Other(Sm ily equif+l,lenl Lykt and nnrdel in Section 1.un PI1pe 21. U (thin'IS 'cif et ui imcro L )c nn model in Bastian F.rm Pape?). <br /> Tun 11 ID:IJ .., ___ Tun '- - _—_ <br /> r9A�lo U In=1'rmk ng Probe. Mod <br /> Jj h1=Tank Gauging I'rohc, Mn11aL•. - -- _.. -- <br /> to <br /> U Annular Space nr Vault Sansur. Model: 1 ,_ U Anmilnr SPn1u I' It Sensor. oder: <br /> —. <br /> UPiping Sump/Trench S<nulr(s)- Madel:— .�(—). U Piping Sump I' -I Se . Mudcl:—. <br /> _ ❑ Fill Smnp SrI a is) no cl: <br /> U Fi 11 Sump Sensor(s). ModeL._ (J(>l� U Meuhuuieul Li ,eek DULLctur, Mot c. <br /> .0 Mcdlunienl Li a Lcok Defector. Model; >LL. U lilcclruti me Leak Detector. MrKlel: .\�- <br /> U 1?lecfronic Line Leak Detester. Mudul: — p Tlu+ vcrfill/I-lig(Ac.vel Scnsar. Model; <br /> U 'I'anA Overfill/I ligh-Level Scaanr. MOdrl: _ -. <br /> G Othrr(s ccif equi Ment type olid model in Suchen F nn Ira c 2). U Other(s ecif c ui mw.nI ty a raid mndel_in Scetion L on Pa�e 2). <br /> / Dinpeusel'ln: < �1 <br /> U Disperrser t'nnurinnwnl Sensur(s), Mudel;_ _ ._ U�-�' U Shelf <br /> Vllr u(.%). mment ScnwrR;). Mndcl: ..,...—_ � <br /> U Shear Vtdve(s). U Shear iser C nt <br /> U Dis -tiger Conlainlnrnt Ploul(s)end 0lain(s). <br /> O Dispenser Coll[alnlneul Flnnt(s)and Chuin(51. <br /> _ Dispenser lU:_ . _ - <br /> U Di.vpenner('unluinmrnt Sensotx). Morlcl I&j- 13Diaf>vnecr Containment Seusor(s). Madel: <br /> O Shen Vulve(s). <br /> CI Lheal' C(g). <br /> Diz tensa C'onbliun)ent I)loats)and Chain(s)- <br /> U L1is miseriser Cunlainmcuf Fluat(s)and C'hain(s)• 13 <br /> Dispenser IU: S ._ _ LUDispenser <br /> nscr IU: ...— <br /> U Dispenser CoutS, 'r nl 'cnsnr(s). Match. —„ �f�-•� ('ontotmucnt Setisor(s). Model:curValve(s). <br /> U ShcarValve(s). ig,ensel.Coului11mcnt Fltsii s)and C'hnin(s). <br /> UUia ens'cr C'ontainmmd Flmtts)and Chain(s). ^^--- . <br /> •Iflhe facility wnl:lins more Ixnks ur dispensers,copy this lino). Include iul'orntatinn everyalwatid lspeu>e�ltl file racil y. <br /> �' 6 i+C`llhd/Yr;lMeeid 'ifl accord Me,with the <br /> C. Certiticatinn - I certify that the equilnnnnl identified in this d1 •un cut's as ta,P <br /> lnanufacturel'Y' guidelines. Allached to this Certilica till', is iltormatian (e.g. otnnufactamrs, checklists)necessary to verify that this <br /> iufunnntton is co1'I'efl and n Plat filet sllowinC the layout of mnm <br /> anering equipent. Far Lou equip 111010 capable or gen:rnfing such <br /> of the re arl; rhoeh rdllhal r(pph'): QySys m ft- It�m hiatary t•epm•t <br /> re pmts•l hove nlsa attacb`d a ropy P`/ ( V•0 / <br /> 1 Sianahixe, <br /> TechniciallNamc(print):- <br /> Certification No.:_n/o(15. -- <br /> License.No..Aar- tJ <br /> 'restingC'om wry Name: I -- I'huucNo.:� <br /> 1.t[ Datc u('Testing/Servicing:C '� /t_—�_• ) <br /> Site Address: 1 —... — <br /> a3m, <br /> Monitoring System Certification <br /> 1). Results of Testiltg/Servicing <br /> zoom xVJ Of:ST soOviTzico <br />