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NION M# -G SYSTEM CIRTUICATION <br /> For Use A,2v.411,,urfsaiallrins rYithin the Stare a%Ca&brnia <br /> utl2ariry C ire�i: Citapt:« 5.i, eaith arra �ziers Cade; Chapter 16. Civisivn 3, 'i itle ?-. faiiiorrria t'aue >i'iteb dation <br /> -nus Farm mtmt ae ad to J=ment ;.ung and ,erm-ng of awni=ng :=mmnem -IL se=amte cmc anon or art must je- <br /> urmarexi tr=cit majiftoring, so, i==I by the twhmcmu pito " rms the work. -k copy, of tris Fsrt mt= oe provided <br /> M the q s-ystcm o r. The-jw=1QP=tGr must sumnia copy or:itis form to the ?ocni agency reg-aim mg UST;vsmxus <br /> within 30 days of test date. <br /> A. Qner:mt Imformation <br /> Faci3iW Names: r�f-:t- dgknv- ( S-- v cc Station No..- <br /> Site <br /> oo.:Site _ City- ��Gt� Z.iv: <br /> Facility ?mWxC ZTo.: <br /> maiwboclei a g S, wcoij 735/oo6 ]Date of T f servicz <br /> B. fuyemtot7 (d Fqa*nent TeOWCerd&d <br /> Check the ww"Niate boxes to" i <br /> T m: 7 9 7 Tank ID: 21 <br /> Sm=or Yanit Sensor a H-rkSpace or Vanit Mods: 4 <br /> (s): 1 -imkwS T r(s): . <br /> S (s): S (s): Liode-I <br /> hanicai Line L=(c Deu=tor. Modek NCO Line L=k D r. V i s7 L <br /> - CElecrronic Lanae Lzak De=ur _. . <br /> OTauk Ov -? _ ±--]TTavir flv 4evei ' . <br /> _ S . in Section,E on P _ S and model in Se.--don E on Paw 2 <br /> l T. ID: t Sal' C Tank Il?: <br /> -T / C -�' Cxau Probe; filo dei: <br /> t Spac=or Vatnit Sensor Model: T-S'/57 OAnnuiar Space or V )AX-L-A: <br /> ' S T (s). � ' S -' (s). i <br /> :ll S ts):rt CFf Somp Sexxsor(s): <br /> gkiecilanicat Lime Leak D Lane Dtiector. . _ -} <br /> nic Line Leak Detector Modek -MEkcwomic Line Leak Dctector Niodek <br /> eC:Tank Ov igii?eves CTank gic-ire:Sensor. <br /> ' ,S mw in Ean , S <br /> fit: — DisyenserID: <br /> C <br /> Spar Vaive(s). Erihew V s). <br /> C2D!3!M=Conwinumm Float(s):roti i s) CIDimnser C=tmnm=FIoatW and L si <br /> IID - <br /> Dispenser ID: 7 <br /> =I'spenscr Co . _ t ,.,,/is C _Sensor(s): s: / <br /> er'shear Va1ve(s). [ Shear Vbf*s). <br /> ODisoemser Containment Fioatts)and Chain(s) CIDispmser t'numntmenr Haoal(s)and Cltaints; <br /> Dispenser ID- Dispenser ID. <br /> OD- . Modei: CPispenscr Conufinment Seusor(s): Madef --- <br /> 0 Shear Valve(s). Ci Shear Vaiveils). <br /> Coummnm=F?oatt"si and Cbain(s) CIDispenser Cantaimuent Float(s)and Chain(s) <br /> *TI the &clity com=ns more ranks or dispensers,copy this form.. Include mf om br-rery rank and dispense:A:itis <br /> C. CZrti itCItion - I ccrti* ehat tate �quipmnnt ideutWwd in this t was iaspecsedlser^vicezi in a=urdance with *he <br /> nanufacmrers' nti -knac�t)ed to this C2rifflA=tion is information *z,. a wufacntrers' check ists►aes s srf to verity that this <br /> :nformadou s carrect sod ; ?'los Man sito ' he ?ayout of monitoring cauipmeut For zny equipment =uabie if.-enerating mcn <br /> _'£{TtirSS, .Y.'•3]!YC:Slsa 3ttaChei1 sco V t'Ch�e'{for%: (e.Ker.Jt ZU r*m ) ki <br /> 7ecinucian dame i Print;: Signaum: <br /> Z mficauon No. Lccuse-No.:' <br /> esung Comuanv Name. Cha ou-7 inion Testing, `nc ?)wne`(4.: f 9 1>) 32?- 5 <br />