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MOAVORMG SYSTEM CER3 M* <br /> . . :..,.�`'. FOT USe�t'U/I�ItLfChdl0KS W11I711Z tj[GS1Qfe OfCQr[fOl7itQ . .' _ <br /> AwhorayCited:Ci.q mr6.7.Health and SofetyCod4;(aF q arl6,Dmuwa3,?itie 23,California CodeofRegu[ativns <br /> This fomt must be used to testing and savieing of monitoang A separate certification a ttioort must be otu�art^d <br /> for by the technician who performs the yuck. A Copy of this form must be provided to the tank <br /> syst,cm ownedoperAm Tie ownafoperator must submit a copy of this form to the local agency regulathig UST systems within 30 <br /> days of test data <br /> A. GenetmIInto do <br /> Facility Names Bldg.No.LA7_ft?_ _ <br /> Site Address: E.• at <br /> Facility Contact Pcxsow Contact Phone No,:e1� <br /> Make/iviodclofMonitoringS bate of Tcxtiug/Savuxng: <br /> B. Inventory of Equipment Teste&Cerdfied J - <br /> Ch kthe - b*wstft.&cace <br /> IT= <br /> TankCungingProbe. Model: Lm-TaakC Pm6a Model Mb I <br /> SpaoearVaakSeum Modd: A=tdarSpaee«V8*S� Mold: <br /> rtngSuwp/TrcachScasot(s). Model: P41ingstmap/TieudrSaasor(s). Model: <br /> lSuWScasac(s). Mudd: FillSuaapSeasor(s). Model: <br /> oharna UwLeakDaoctow. Model_Z1WZO J �[ModraniatliwUakDc(aaw Modd: 4.� <br /> c ftQdicUwLakDctoc". Mudd: ®EtoaranielineLeakDaectoe Model: <br /> kOYaW1Wgh-.vMSensoG Model. c+ _ {OCA Tx*O�xStt/Ife1ACVdS=m Moder _G 41ist <br /> crt and model in Section Boa 2 rG <br /> Oma'( and model is Section Bon - 2 <br /> M.- nkID: <br /> ®to-Tank Caggutg probe .Model• U-Tauk....g Pct Model:❑AnatilarSpaoeaVaultSeuso4 Model: AnnW&SpaworVankSensm Model: <br /> O Piping sump eTrcnch Scasor(s). Model: ❑ Piping Sump/Treacb Sensor(s). Model: <br /> 0 Bill Sump (s)• Model: 0 Full sump Sens x(s)• Mold <br /> Q Mcchanial Line Leak Detectm Model: 0 Mechanical Lute Luk Dctoaoc Model: <br /> O EkcUOnk Line LcakDdtoaor:. Model:._ 0 Uu-_L cak Daoaoc Model• <br /> 0 Tank Overfill/Ifrgh-IavelSensor. Model: 0 TankOmfill/]ftg&-LevdScnsoc Modell <br /> t1 Otho(s ui taid model in Section Eon P e 2). ®.Otho(specifyequipment two and model in S00600 Eon Page 2). <br /> Omer <br /> D"rspeczser ID: ispLD: <br /> ispegsaConrainnucntSenso((s) Mold: DispcnserOontainmentSalsoc(s). Model: . _ <br /> VSiEm.acontainnxnt <br /> hear Valve(s). Shear Valvc(s)_ <br /> Float(s)and Chain(s)• Di Containment Roat(s)ar d.(Itain(s). <br /> Dispenser ID: `Dispenser ID. <br /> ID"rspcnserContainrncn(Sensoc(s). Model: 0 DispenserConwnmcn(Sanot(s)_ Model-. <br /> Shear Wve(s). D Shear Valve(s)- <br /> DispenscrGonumment Floats)and Chain(s). ®RLTME Containment Float(s)and Chain(s). <br /> D"cspeasez ID: Dispeaser ID: <br /> D-tspanaContainmentSensor(s). Model: 0 DispenserContahunaxSensor(s). Model: <br /> Shear Valve(s). p Shear Valve(s)_ <br /> DD Containmcm Flo3((s)and Chain(s). O RLseEM Contatrmacnt Fioat(s)and Chain(s). <br /> ,,If the facility contains mote tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. <br /> C. Certification-I certify that the equipment identified in this document was inspectedhetviced in accordance with the rnanufachrr^ers' <br /> guidelines. Attached to this Certification is information 0-9,manufactutwV chedidists)necessary to verify that this information is <br /> correct and a Plot Plan showing the layout of rnoaitoring equipmettL For any equipment capable of generating such reports,I have also <br /> attached a copy ofthe -(ch all ply): System set-uphistory report <br /> Technician Dame(print): Signattuc <br /> Certification No.:— bb�v license.No.: L <br /> Testing Company Namc:M:,kn Phone No:(8 ) - • (�a <br /> SitcAddress:Z51��i r� ,,k 'flu d:it•� 1c eA 9tSoS Date of Testing/Servicing: <br /> 1'a--c 1 4&3 ptmt <br /> \Iauit<.t-ia;�aarui Cartilirtti<ur <br />