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01/82/1995 03:27 <br />MONITORING SYSTEM CERTIFICATION <br />For Use - <br />Authority Cited: Cliapter 6.7. Health and Saj6y Code: Chapter 16. Division 3_ Title 23. C410rn14 Code or•RegulRnons <br />209/ 46722 CALAVERAS ENV HE TH PAGE 01 <br />This form MUSE be used to document testing and servicing of monitoring equipment. if more than one <br />monitoring system control panel is installed at the facility, te certification or xevoti mug t nreoamd fx <br />each moatigancl by tate technieian who performs the work. A copy of this foam must be <br />provided to the tank system ownerfopeaatoT. The ownerloperator must submit a copy of this foam to the local <br />agency regulatin UST systems within 30 days of test date. Iaastructions arc printed on the back of chis page_ <br />A. General Ixformation <br />Facility rrr�/v <br />Sim Ate; / .�/ l City- � I zip - <br />Facility Contact Person: Contact Phone No.: OC6��- 11l <br />MakdMa&) of Monitoring System' jf ��' �/ 5. " 3 S LS Datc of Tcsting/Servicing: 7 . <br />B. €aventary of Equipment Teste&.I�ertKled <br />C. Certification - E certify that the equipment identified In this document was inspectedlserviced in'ccortlance with the <br />esmufaettarm' gukleHum Attached to this Certiiacatioa is information (e g. wassfacturcrs` checklists) necessary to <br />verify that this informations is correct and a Site Pian showing the layout of monkoring equip t. For any equipment <br />expatde of gmerathag such reports, X have also attached a copy of the (check all that appplp): 0 System set-up re <br />/ �0 Alam history s <br />TechnicianKtme (prim):G'� / �/ �/'/ c tjuc. No_: .-� ct" si <br />Testing Company Name: i%"1 �K G 170TT6,±tie No.: � ) 537— <br />tsoa!-�' Fax We 7671 W62/75649" <br />► <br />ro s+ww <br />co,u«p.Ell(- co. <br />2-d 2ir69- T 9* 1602) untoag a l ijeo dofs :2o 6o E0 i nr <br />