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AFF ORDA-TE*T 209 794 0112 P. 02 <br /> POO 36 26511:K SACTO. UL. <br /> riORKTON, CA. 9568-5 Continuous Monitoring <br /> 000170A _24-9087 Device Certiftation <br /> 0 3 2 S:A �"LEST DAT9 <br /> N CTO <br /> 6"': <br /> " 6 T <br /> N ON� CA 18 <br /> 1]09 7: 24-90:87T <br /> UST DAT19 <br /> (PPRIM"Rf-6-il OWNER <br /> ADDRESS <br /> 1�1 V UT <br /> PHONE <br /> MME AND MODEL OF MONITORING 8VSTE,,__L. <br /> Contents of Tank ___f"R1LL41tj__ -TAMK2— <br /> CapWty of Tank <br /> Type of Product Line. (Gravity. ucton® Pressure), <br /> INOGATE LOCATIMI OFT MONWORING SENSORS TESTEO By PLACING A YES OR NO IN APPLICABLE BOX; <br /> Annular Space Sensor <br /> sump sensor <br /> Dispenser Containment Sensor <br /> Electronic Overfill I Level— <br /> Electronic In-Line Leak Detector <br /> Mechanical In Leak Detector <br /> I n Tank Gouging Device <br /> INDIGATE IVIE FOLLOWNG BY P.LACING A YES()R NO IN APPLICABLE BOX: <br /> Ems the moNacring system hwe wdible and visual almmr.? e4, <br /> Does the <br /> to auWm*UCW WM-down If the system detW9 <br /> a look,bib to operaft or is etswunIty dsoonnacted? <br /> IS the <br /> r6 °r# systam hishad tD prevent unauthorized tampering? <br /> is—to nwftring system opwable as per the manufacturees speeffications?77—'.75-1 <br /> ftich continuous mriftorIng devim InNate'positive shul4own of the tet Mne? <br /> CERTWED TESTER'S IDO <br /> SIMATURE OF CVff]FMD TWWCIAN <br /> PRIKMD ItAME(W CEATIFIED TEECHMPM <br />