Laserfiche WebLink
(02/1995 03:27 24 <br />MOND <br />.thorny Cited: Chapter 6.7. <br />NG SYST] <br />CALAVERAS ENV HEALTH 01 <br />%I CERTIFICOKTION <br />r 1!S? Dt mite 13. California Code of Regutations_ <br />This form must be used to document testing <br />i equipment.., If more than one <br />monitoring system control panel is installed at the faeili y, a to c rtificaitn or rt mu f <br />each mo_nitaristeffi �nrrrm) uanclMiy lite Eechn;an wha� erforms tie work. A copy of this form must be.; <br />provided to the tank system owncrfope:eator. Tk owner/opOratof must submit a cagy of s fog to the local <br />agency regulating UST s ems within 30 days of test date..�'Instructions <br />are ponied on tilt back ofihis page. <br />A. General Information <br />Facility Nasse- Bldg. No.: <br />, <br />c a dr�rese; �� City- zip- <br />Contact <br />Facility Coatac4 Person: _ Contact Phone No.: <br />makeimodel of Monitoring System: Date of Testing/Servicing <br />R, f nvetut®ry of Egsttpnteat Teste&Cetdtitr3 <br />y,. <br />E <br />C. Certification - I certify that the equipment identified In this document was inspectedfserviced in accordance with the <br />nianufact ' guidelines. Attached to this Certification is information (e.g. m it"facturers' checklists) necessary to <br />verify that th{s information is correct and a Site Plan showing the layout of monitoring equipmen For any equipment <br />capable of generating such reports, I have also attached a copy of the (check alt that apptyj: ystern set-up report; <br />rtn tory port- <br />Technician N t): _ Ccr%Aic. No.�--Si"turc- <br />Testing <br />Company Namc: i Flionc No._ t a <br />