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MONITORING SYSTEM CERTIFICATIONCarR= latrans <br /> MFr;r rs�-:. .:.'/u�: ,t:cIIOR3 <br /> Authority Cited: Chapter 6.7.Ifealth and Sajery Code:Chapter!6.DivisioK 3. Tit/c 23. (ultJornta Co SM' <br /> and servicing of monitoring equipment. If more than one <br /> e <br /> tt-ceruficatio n mu t <br /> This form must used L anent tall d a he facility,a of this form must be <br /> monitoring system control p the technician who erforms the work. A copy <br /> r,rtrrol panel by P of this form to the local <br /> each monitot s tar. Thc owner/opetator must submit a copy <br /> provided to the tank system o`'mc em rimed on the back of this Page. <br /> a ency regulating UST systems idn 30 days of test date. instructions are P <br /> g <br /> A. GeocrllInforn%adqu / �� <br /> Bldg.No-:__� <br /> )actliry Name: . (' zip- <br /> F /5 <br /> City" <br /> Contac one No. <br /> Fatil►ry Contact Person: ' <br /> X-� Date of Temng/Serv1cwS: <br /> c/Mode of Monitoring System: _ Sell //G <br /> 1�tak <br /> B. Inventory of Equlp t¢'-'�•-ste*lJCertified <br /> fEc nutem,", <br /> ins eeudlser+fced: <br /> heck free a e crate boles to indlnte s Tam ai. `^ - Mode' <br /> �S�{3 '� ®tn- a C°"stt l;r�ooe. c o <br /> T jD; 1/12.. Vault Sensor. Model: <br /> Mode r— �_ d 0 Annular Spit or Model t <br /> a tn-Tank Gauging Probe t Mode: 17 n,prtrench Sensor(s)- <br /> ® Annular Specs w vault Servo c (9 Piping Su Model: <br /> ��5�, ,)jtur,model: 0 fill Sump senso*(s)- Model: <br /> (l�Piping SMms�f Model: ❑Mechanical line Leak Detector. <br /> 41 Fill Snrnp Scnso+Ls) Model: <br /> O Mechanical Lme Leak Detector. 'Model: Electronic Linc Lea/ IXt l s or. Model: <br /> Model: ❑T�Ovet{ii1!HigR-i.cvci Senls <br /> tl�DetectOT. nt 5�5pr(S). Model. <br /> Electronic Lice Level Sensor. Model: Q Disprnser ContaMnttte <br /> D Tank Overfill 1 liigh- Model: ve)ve(S)• <br /> ® Disprmer Cootusnrrcnt ScnsoT(a)- ❑S1Mear t p'loat(s)and Chemin). <br /> �'Dupencer C°atatnme+t and model in Srction E on Paz <br /> Cl Shex c'- <br /> valve(s)- cifv ui nt t <br /> Flost(s)and Chain(s). O Other s <br /> 0 Duprse Conor and model in Section E on pa't'--) T&nk ID: Model: <br /> C] other(s cif ui ment ri <br /> t ❑ in-Tank Gauging Probe. <br /> Model 4Z Model: <br /> Tank 1D: O Annular Space or vault Sensor. Model_ <br /> In-Tank Gauging Probe. ii clt 1 ;C ) rench Scnsor(s)- <br /> tx vault Sensor. Model: x ❑ Piping Surrtp� Mode: <br /> p Aneuler Spxe renrh SensoKt) Model: J -797 f'� ❑ Fill sump S—of(S)• Model: <br /> ( piping SutnprT ❑ Mechanical Linc Leak Detectot- <br /> Modcl: Moret: <br /> ® Fill sump SensoK�) t t Modcl: L._L 0 Electronic Line Leak Drtector. <br /> Leak De ee or- N 4 �' <br /> 1:1 Mechanical Line Leak <br /> l)exetrnr- Model: (]Tank Overfiti!High- t 5 Sensor ----- <br /> c <br /> Model'of Elecuonic Line vel Sensor. Model: ❑ Dispenser Contain en <br /> a Tank pverfrU l High-Le $ Model: 1 ,ft.,U C Q Shur Yslrt{9)- <br /> {-orttr<nMrW Sensor( ) al e(s)_ iwnan Float(s)and Cbain(s)• M <br /> ❑ DispenseT O Disycns and model in Section E on Paee_). <br /> Q.shtw valve(s). Chain(s). L]Othcr s ifv uiomcat <br /> sa Cof"Un ncat Floats)and a 2l. <br /> Q Dispcn i f ui t and model in Section E on Pa accordance with the <br /> p other(s tedlserVLced in cessary to <br /> ui mcut identified is this dautnttst was l� ofacturers' checklists) rte <br /> [ txrtif tuft the tq p yi trent. For tiny equipment <br /> C. Certification - 9 <br /> tsldd��• pttaehed to this Certification is informaout f monitoring� P O Stem set-up report; <br /> manafateturers' Bost is correct and n Site Plan s!►owin of The f ham, rhe oppir) arm bLLst��rr��rr report' <br /> verify Haat this Infos ri I have also attached a copy R n 'r'� <br /> capable of teneratiog such reports, <br /> elw <br /> Si , <br /> L <br /> U �� <br /> Ccxt <br /> Technician Name(pnn i y �% ' 11 <br /> Name: <br /> Co=Pwy r <br /> TestingP e <br /> CJMI•M-ot —� _ <br /> 0 -d zt�E919t,60z out sJ040eJ4u00 AI a'4113 e9S :80 ZD 01 400 <br />