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Jan 10 03 02:22p Ca Brown (20 461-6342 p.2 <br />61/02/2995 03:27 209754b 22 <br />CALAVERAS Etd�r HEAL PAGE 83 <br />MONITORING SYSTEM CERTIFICATION <br />Irk and Saliry Code: Chapter 16. Divix►t <br />ion 3. Title 23. Cal9for <br />Authority Cited: Chapru 6.7. flea <br />ta Coen ar, Regulations <br />If <br />more than one <br />This form mast be used to document testing and servicing of monitoring qunPment mut,rr-nared for <br />monitoring system control panel is installed at the facility, to <br />cert;ficatieach mon'tori s anti by the techtaiCian who performs the work. A Copy of this form the local <br />provided to the tank system ownerloperator. The owner/operator must submit a copy of this form <br />agency regulating UST systems within 30 days of test date. Instructions are printed on the back of this page. <br />A. GeneralInform=tltln <br />/� Bldg. No.:- <br />�-- 'f�6( <br />FaeiSity Nnmc: <br />CnT ;' l zip: <br />Co.utact Phone No.: <br />Fuility coquet Person: - <br />*r Date of Tesmg/Servicing: <br />Makeimodel of Motutoring System: � <br />B. Inventory of Equipment Tested/Certified <br />C. Certification - Y certify that the equipment identified in this document was inspectedlserviced in. 2rcordance Frith the <br />this Certincatiou is information (e.g. mnaufacturc& checWists) necessary to <br />manufacturers' guidelines. Attached to <br />verify that this information is correct and a Site Plan showing She layout of monitoring equipment_ Far any equipment <br />capable of Kenertttlue such reports, I have also attached s copy of rhe (check aUrhar 0rPtY)-- 0 System set-up report: <br />D Alarm history <br />Technician Name (printlJ��%✓t�r�- �ll���%_ Cer(Aic. No.: <br />Testing nYp anY �/ <br />Co Nettie: l��l Phone No.: t � ! `7 r <br />Pf► e 1 OWN" <br />CAt.MOI _ — -•------- <br />p'ostar Fax Note 7671',3 OC, Topa'► <br />Fmm O n q r S <br />coJoad- Co. <br />Pf-om • 7S4-- 9 0 <br />