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MON*9RI <br /> • A T <br /> �g g <br /> Aub ori C 7> . � 1 . 7`i 2 s fornix Coded, I& s <br /> This for7 nvast be used to docurnem testing ar4 smic-ing of mrtitoring equtffmmt A <br /> it ting mstee 22=1,MMW by the technicisftwho performs the wurk. AcOPyofthirknmstbeprovidWmtltetmksystmomw4opwvwf, <br /> Owncvopemtor mud subrmt a copy of this forin to the kwal Agency resulating UST gystoms within 30 days of test daft. <br /> A. General Tari at <br /> FacilityName, ESCALONMIMMART R)d . .: <br /> Site Addzesa. 1097 E.YOSEMffE Cam 0 <br /> FaLedity Contact Person BILL Contact Phone o.: f 38-1 NG <br /> Make/Modell of Monitoring SYMIWI EOW ALft/Sfik Jr.4 Date of Tcsft!Servkfng, i 1=2009 <br /> B. Inventory ofEquipmentTested/Certirled <br /> C +ct thePMOriste bases to indicate werific t 1 <br /> TA#k ID: U Tank f : Premium <br /> In-Tank Gwsins pmbe Mme 9W 0 In-r2akGAL-king <br /> !k las Val knsw Me& Annular Space Gr Vault smser. l�tc 1. LSM <br /> pipi-I ,'Tretweb `s), M : LS3A H fining SwT 1 Tmch s}- Model. <br /> Fill sunv Mi3dafi 0 Fttl5WM sftso*). ?W4 i. <br /> Mmhan=l Line LzalkDomw Model, meciftanIcal Line Lftk Ddcmr. Mode-_RW JACKET <br /> 0 Ni 0 DeMhw Ung Lak Deketar- l- <br /> Tmk Ovwrm#t F -1Tan'k evcruill I Iii st Samar. Model: <br /> C1th (Wwry WWPW,4"And modE'in seefion E'On P2=2)• 0 Othm f t 11W and mdei in Sodion B on Pap 2� <br /> Tank : Tank- <br /> Tn-T k Gouging Tmbe. to-`€ant€Gauginf ftba. <br /> Annul:Spm or Vault SmW. Mo&j: L1 Annular Spat=or Vau t smat modeu <br /> [ Piping Sump l Trach s). m Piping rump I Tftoch" s), tut <br /> Rall Su s). m 11 Flit r (s). <br /> Mechanical L° l: E3 Memnical Lifts Lmk Oetwor. madri. <br /> is Unc,I=k Deftlor Maden 0 Elea rorde t Tk for. <br /> C3 Tank fill I high- el Scmr, model: D Tank Ovatiff J I t h et Samr. Modri; <br /> Dther(spmify equip t typc and MO&I in eeseegm g on Fw 2A 0 other(Spctify Upipn=t old=del in Section E on Pap 2). <br /> Dispatear UD, 112 DIspeow M 314 <br /> c wivera 0 stior vatye(s). <br /> Dispenser caftimms Flees $;me cfti*4 0 a)IA :r ls). <br /> i D: 7 <br /> 015maer containnMit s) t: !6 Flt t ctt,Esfnr� nt5e ssc s). Model` LS <br /> S T Va',,*$ Shear Valvc(s). <br /> 0 DispanKr ContainnWt F1aat(s) s). ®DiWenser Cmtajnwmt r (s) <br /> Wgpensar M <br /> bi 0 s). <br /> 5he&Vslxe(51 0 r ) <br /> Diapcnsa in t and fs) 0 -A)tnd CUM'[s), <br /> Wthe thoilityc<mIzim art€' rs, tnoUft irdbrMalion for every tank and dispmw at the fadlity, <br /> C. Certificatiom -ice y thatm t idmt1fledw this d t in t <br /> guideline& Aftadied to this Certification Is taf . manufaaMrOW checkgM)n 4"t Ws Wernatiffe is <br /> mTed and a Pkat Plan showing the hyaut of mmiWigg equipmnt. For any eqwpmeat capable cneh rWWtF,!mave Aba <br /> attacbed a copy of the repan,&*gjA as that ,). systan � t <br /> Tac ci_ N "rg): Junior Sirtoo, siguaturw <br /> CerdfieafionNQ_: 122621376 <br /> page 1 of 3 <br />