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Appendix V1 <br />(Copies of 1lrfonito6ng System CertiftCetlOi; form and UST coni?arirfg Plot Ptah available at ,aJi:�-:t 'x'. �''t�«::e. �`7°i•) <br />MONITORING SYSTEM CERTIFICATION <br />Fcr Use By All .:ur7Sv"'iclions W4h rt Me State of Ca(ilornie <br />Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califamia C068 of <br />Regulations <br />This form must be used to document Zesting and servicing of monitoring equipment- A separate certification or report mual be prepared for <br />each monitoring system control panet by the technician who performs tte veorfc. A Copy of this f4r7t must be pmvi&d to the tank system <br />owner/operatar. The ownerfoperator must submit a copy 9f this form to the beat agency regulating UST systems within 30 days of tit date. <br />A Generai Information r} <br />Fabilly Name: —17_ ,p 8tdo. No.: <br />�� <br />Site Addass: �_ � i �d�—� CiN _ zip' -- <br />Fac:tlRty %ontarA Person ©wr - — __ Gwit,d Pleurae No- <br />MakeWModel of Nfon40ring System: Data uf Tesia1,gi5ervicm9: <br />a lav ntnfv of Famornent TestedlCertmad <br />C. Certification - t cort"y that the equipment identified In tuts document was inspacheA %erviced In accordance with tate manufacturers' <br />guidelines. Attached to this Certification Is Irtfarnwgion (e.g. manufacturers' checklists) necessary to verify that this infamretion le correct <br />and a plot ptan ahowing the layout of monitorin a:quipment For a��II equipment capable of gerwratiirg sumh reports, t fume also attached a <br />that <br />copy of the report; (check ail appiy : _�ystem set-up 331arrn history report <br />Tachrrician Name (,printf _ t Signature: <br />CIO A, <br />Carfificatlon No.: �n License. Flo.: <br />Taeunq Company Nacos: �jj ri 1 Phos a A7o.:l�Tf 1 <br />Testing Company Address: %loserl 1 _ tate of Testift/Servfcing: <br />Ailortitoring System Certification Page 1 of a 12147 <br />2/21/07 <br />