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Oqt 17 13 08:58a Elite IV Contactors 12094616342 p.2 <br />Appendix•Vt . <br />(ED' <br />Copies of Monitoring System Certification form and IJST Monitoring Plot Plan available i htt :/lwwnN. <br />MONITORING SYSTEM CERT1FiCAII •►N <br />OCT 17 2013. <br />For UseBy •All Jurls#dorts Within the Stale of GailhwWa <br />Autharliy Citedr Chapter'6.7, Health and'Sawy cods; Chapter m Division 3. Title 23; co" la bode of <br />Regulations <br />EA QWThis form must be used to document testing and servicing •ot monitoring equipment. A separate c Ort cation o'report must <br />each monitoring system control panel by the technician who performs the work . A copy of this k r must be provided to the tank system <br />owner/operator. The-ownedoperator must seibmk,a copy of this b m to the local agency regulating t. S systems within .30 days of test date. <br />A. General information <br />F�iliy. : 31 N <br />11 �• ;f� - ` J' c r `'7 't. a.: <br />Nome <br />Site Addlr ss: %� / �.t' �` , � r �� _ Gdy,:' ; � ( — zip.- <br />. FacAt{y Coruact.Peison: N In (L"� i t.' _Contact Phone No.; ( rl c 9� <br />r } iC L f yt'S <br />AAakelMadet ai Marttortng System: T_ a 3 .5 t. Date o Testingl& ry 1v <br />B.. . inventary•of•Egtiipinerrt TestedICE itl6ed <br />Check the a ro Piatdbb xes to indicate frc equipment Ins iocted/sirviiced: - <br />Tank ID- ` jai. u t 1. Tank -R ' ' - - • - <br />L fn Tank Gaarging Probe Modal u in -Tank Probe. Modal: <br />r. Annuiar'Space or, Vauit-Sensor. Model: moi,'.: -p Annear Spaoebr Vault Sas: r Mgdel: • <br />JZ' Piping Somp/Trench Senscx(s). Model,'-Z,','ri 0 Pond Sump/Trench Sensor, s) Model:. <br />•C jU Sump'Sensor(s). Mocfei: 0 Ffr l Sump'Sensor(s). Model: <br />C MechanlcarrLlnaLeak.Datector. model: - D Mechatr[cal��neLekDetevtcr. Model: <br />;C . Elemibnio Lrie leak Detector•. Mallei: " - 0 Electronic Lina Lank Detector. -. Modet: <br />C Tank Overfill /High4Avel Sir. Modes G Tang OverNJ High -Leval Sas; Mori: <br />z.:Othbt., gd ent W model in Section E ori P 0. Outer a u 6 air model In Section Eon Pa 2i. <br />Tank7D: Tank W.; <br />0, In -Tank Qauging Probe. Model IrrTank Gauging Probe — Modal: <br />c1 ` Atl�rspe or Veuft 54nsor. higdet: u Aneaular $pace or.Vautt Penso. <br />`C . Pipt6ig�Srrtnp /Ti0oh Sensorfs} Model: D Pipirig SfjmpJ.Trench Sansor(sj. Mogi:• <br />C: --For i Sump Sensor(s). • . Model: ❑ Fill•Sump sensor(s)- Model: . <br />C Mbbha' iIQW Jne Leak l)etector. Model: D Mechanical Line Leak Detsctcr. Model: . <br />C IedFprdc Lute Leak'Detecfor. Model: 0 .Electronic tine Leak Detector. Model: <br />C :Tarjk• Ve til J-motes-evolisensor.. - _Model; 0 Tank OvadIO-H6 -Level 5en:or odai:• <br />C• t7ther. d e o ent 1 e and model In -Section Eon P 2. 0 Other s aci nt i n model In Section E on Pa 2 <br />"' nsef"7D'c, blspenseri0: <br />L ContainmentSensor(s). Model: U• DispanserContalomentSensbr(s Model: <br />C-.Sfiear.Valve(s). 0 ShaerV�re(s). <br />Dis nsar ContainmentFina B and Chain(s). 4 0 or Containment Float o a J Cliln s . <br />D QED: Dispenser 1D: <br />f~'?) fgi� r:Caftfainni®Fit'Seris6r(s-): i dw, 0 ;Disp@pspr Ctint$inmept $ertsor;s� fvlotief; <br />":StaearUaNe(sj. ❑ StieerrVsive{s). <br />C.::;i?iS er Comainmer� Flom s .and t^,tralri s _ •0 Dis unser Cantainment-Fi6alsi® :i Ghats s r <br />Distpt&er iD: Dlepmtaer fD: ' _ <br />`C Dieper ContelnmentSensa•(s). Model: D .Dlspenser.Cantalrgnenr5erx is} Modal: <br />,tshea�uaiue(a}. ...: , :•.. ...•._- - .0 •'St;aaruaWefa)::-> • . ,. . <br />tainmwtda st s w '._ _._ .. ... . ni t &i ► s -- . - �; -=-- <br />;;'If (toe eoility Ggntains more tanks.o _ ptrrrsers;_copy this farm. !n<duds Inforrrlaflon fol every farif(,and.01#ponaet et•tt . eRliI <br />r .:cad Atititt ` Li ify that tlm.: jcrlpment_tdetrtiftei!_iu_tl�s s alnspE i dlsaviced_� a �rdatrceautth lha-rrraiatifacirrrers'----- <br />g¢e�ne /{ttaehe{l;.ta.ti�la..(roti&s�liNii>i°tt3forrttation.(eg manufacturers'checkttsfe),neaessarytov ify.trot.thlslnfornratiariiscornsct. <br />and a Piot Plop show rtg the layout of montioring`squipment. For any equipment•capab)e of.generating ooh reparis, I trove also attaghe d a <br />feet ". 0-Atar fat ra#t It �-� <br />..•r n.t...a Acid kfkGd§tik%deVb'bW°`:is a»I 4•nw�R30n.+a.ar {euL ryp. w. - s -x ' Y77's : ...a. ,P.Jr, ra«. j^. V..J' f ✓ .Mi.d 1.• ..v .,,.w.. . .. v - , ... .. a.. ti,,,,...:, <br />Technician Name {print).— <br />Cartftatlon Imo.: tltattse. Na 0 L `C it <br />� i Qomm�y Namee r od✓ / Phone No.: � j 01 :11! ': r <br />"Fe+stlftg C&IOarty Adryt§ss: �� � '1 �� •..� �>� ✓, ' � a,,;,,, i7ata of TastinE tS ^afcki9: 14,t ;J I <br />Monitoring B*81n Cedlfleation Page I of Q t21Q7 _.-._...- _. <br />1 2121107 <br />, <br />