Laserfiche WebLink
May 14 04 12:18p Car -e Brotun (20 461-6342 p.2 <br />01/02/1995 03:27 2097- 2 CALAVERAS ENV HEA1 PAGE 01 <br />MONITORING SYSTEM CERTIFICATION <br />(-L"/• /.'s�:,' :..' Iurest:GUOKS Ki: :-, ". <br />AuthOrtry Cited: Chapter 6.7. Ilealth and Safety Code: Chapter 16. Division 3. Title 23. California Code nr Regulations <br />This form must be used to document testing and servicing of monitoring equipment. If more tban ane <br />monitoring system control panel is installed at the facility, a se��m4e G�ficazjo zeport trust }c9!mo-far <br />ach monitoritwt: systcl Y m <br />and b the technician who performs the work. A copy of this formust be <br />e _ <br />provided to the tank system owner/operator. The owner/operator trust submit a copy of this form to the local <br />agency regulating UST systems within 30 days of test date. Instructions are printed on the back of this page. <br />A, General laformation <br />Facility Nazm: Bldg. No.. -� - <br />j/,>�� city-( 2�a: <br />Contact Phone No.: 3 8 y <br />cility Contact Person,- <br />Fa�,� � - -- <br />Mat<eJMadcl of Monitoring SystetA: ) / i)ate of Testinglservici�ng: <br />B. Inventory of Equipment TestedlCertifled <br />C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the <br />nnanufacturm' gaidelince. Attached to this Certification is information (e.g. mitaafacturcrV checklists) necessary to <br />verify that this information is correct and a Site Plan showing tate layout of monitoring equipment. For any equipment <br />capable of generating such reports, X have also attached a copy of the (check alt that apply): 0 System set-up report; <br />s ^ history report. <br />Technician Nunc (print): CertlLic. No.: Signature: f <br />U yG - Phone No.- <br />Testing Company Nano: ! <br />cem.mt-ot Page oarr3r91 <br />pom4' Fax We 7671 txa�? Y � ' ► <br />ECD.Oftrho- <br />on Qr�a'co. <br />w 461- <3 2- ' l5- -- 9U <br />