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01/02/1995 03:27 2097545722 CALAVERAS Et,N HEALTH PAGE 01 e7 <br />MONITORINGSYSTEM CERTIFICATION <br />Fcr US. ..:..' Ittrc:.cxtiOxS K'� " <br />authority Cited' Ghapttr 6.7, Neadth and Saje{v Code: C.htspter 16. Davisiox I Tide 23. Cadifomed Code ni Regudattons <br />Ttlis fors must be used to document testing axed servicing of Monitoring cquiPrnent- if mare than one <br />monitoring system control purl is installed at the facility, te certification ort must -fx <br />each rnonitorinit sy tG11iCQII anal by the technicians who perforans She work. A copy of this form must be <br />providcd to the tank system ownerfopeTator. The owner/operator must submit a copy of this fottn to the local <br />agency regulating UST systems within 30 days of test date. hnstructions arc printed on the track of this page. <br />A. General Information <br />Facility Name: 1 <br />Faculty Contact Pcxsoa: <br />It <br />7 � 4;; A: �e <br />Bldg. No.: <br />chy- <br />Cowact Pho1w No.: ( l ) <br />Dawof%nss <br />sg/ScMczng: /✓� <br />N(xke/Modc3 of Monitoring SYstC= <br />B. Inventory of Equtpatdat Tt't-t&Cet fJ0ed <br />C. Cerrtitfcat kU - C c mify that the equipment identified in thfS document was inspected/serviced in accordsncc %with the <br />msnufactureW Ines. Attached to this Cerolleation is information (e Y. maaafactureW checklists) accessary to <br />verify that this information is correct and a Site Plan showing the layout of mooltaring equipment. For any equipment <br />capable of =eamdue such reports, I have alto attached a copy of the (check alt than aPplyt: ® System set-up report; <br />history r rt. <br />Technician latae: {print): (!!�// J�%C *� / .: CcttjUc. No.: Signature: — i <br />Testing Company Name: & / i / .- Phone No.: <br />'Gtr-n'tes p t-_•__---___..- oatzsts� <br />p'o!t r Fax [tate ppo <br />Pilo- w <br />'75- 4— 9 0 <br />6.0 Eipe9- T 9fr ( 602) umoig a i ije o dot,:20 60 60 I nr <br />