Laserfiche WebLink
W . O . # NW1 - 2337994 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM Ill I rAt <br /> This form mustbe used to docranrniteaenaond An Mr in a of ondersanrnda Ielrxw nns rret r l mrAus+r+rV �Tr�ppmneM . Aurpy nl fhM Fenn <br /> mualbA Pr=Io lha ilei ownorM operAlrrr , Tho GWMfar opNltor mu&I AetATl Aer• Py n1 IIIA tom to thefatat Agency royWng the <br /> DSTa within 70 days of the dale of the manIto ring ►VIA ISM CWfit kM'on <br /> . <br /> L FACILITY INFORMATION <br /> f)rls sa Mame Same oA I acdaylvamoor llLL . aG g &ssnleas 1 f <br /> GY jp — <br /> tkrslneso5a dMese <br /> 11. NDERG OUND STORAGEVICE T HN161AN INFORMATION <br /> Mann of Qmpany TMferml The Ceitfknlsn <br /> vv u 0 tr[ ) kT i,r{ et <br /> h iing Aodreae el zz rr <br /> NameT Servke Technk4in Ftirlorrrin8 the CerWkG (Prrnf es s ^ M Iha IC ' Canhce9on 1 <br /> r- •l ICC CerUcaOon faG*a!nn (?are <br /> ContracloflTank esterLicense # ICC Certification <br /> L/ `- II Vbrw 7 <br /> V2.0n S stemTraInW Grid Certkkations List elle dical corlrealons nen 0era <br /> 111. RESULTS OF TESTiNGISERVICING <br /> ndfcale anda trach thefol ngreports If the monitoring equipment 13 capaboo genel =w'ff "art Y N NA �� <br /> B^hT.ndorlog systemsel-up PAbtm his tory Report <br /> Was any rmndmi ng equipment replaced? ❑ ❑ <br /> (If"Yes, "ndenllfylhe specific de Ncesreplacedand list the manufacturer andnrodel for all replacement pads in section Nbelow 1 <br /> Wasdanage, debris, orriquid found Inside any secondary ccnta'n nl systems ? ❑ ❑ <br /> (If 'Yes, " descdbe chat ties foundmsectionlVbefow) <br /> Is al monitoring equipment operatonalper mnufacturer's specQ¢alons? ❑ O <br /> (IPNo, "describe tshyin section NbelowJ <br /> IV. COMMENTS <br /> If recfedto use this section, describe howand Men fheissuesxereorrxilbacerrecred <br /> I <br /> 1 <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I <br /> I hereby certify that the equipment identified In this document was Inspacledlserviced in accordance with California Code of i <br /> Regulations , title 23, division 3, chapter 16, section 2638 and all Information contained herein is true and accurate. Attached ti <br /> this certification is information (e.g., manufacturers' ehecklists , monitoring system set-up, alarm history report, etc.) 11"essa <br /> to verifythat this information and the site an showingthe la out of IT <br /> s tem Is complete and accurate. <br /> UST Se chnkiansgnatum <br /> C68 = Caffomia &n iormentaRbpor*V 9ystom, O=idantficdion, ICC • htelllsCaralCode CourA Ya Yes, N : W, NA x N>t app►.-+ble <br />