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8-03-204 1:09PM FROM .AN JOAQUIN COUNTY 209 4683098 P.1 <br />MO RING <br />SYSTEM CERTIFICATION <br />For Use .authority Cited. Chapter 6.7. Health arta' Pf tY fp' Ch Within <br />Dtvtion the State 3 e a3t Ca/ fornix Code of Regulations <br />This form must be used to documnt testing and setviring of monitoring equipment � nice certiitca' <br />P hared fQr , ch rtt n'torin ;taboo► t9M2 by the techn�cittn 'wlto pe the waric. A► �4 teDO mu�� <br />to the tactic system owner/operator. 'Thi Owner/o razor mast submit a co of this form to the logia! of this farm must be pnyvidi <br />within 30 d�tvs of test date. agency regulating UST systems <br />A. Genera <br />Facility Namc <br />Site Address: <br />tr No.:t`� 1y,� <br />zi • �s�_ <br />Facility Contact Person: V. <br />Contact Pizarro No.: �) <br />M e/Made! of Monitoring System: �"LS --: ego Vt1�n— `=R Date of TS / � 61 p <br />B. Inventory of Equipment Teste&Certitied <br />Tank M: Uk1 Lt <br />�,n Tank—G=&& Probe. Mtdet: <br />.XArua *r Space tar Vault Sa mr. Modal: <br />Pipits Sump / TrM4 Smsprw- Model, _ �5' <br />Will SUMP Somas). Mdal <br />o: S <br />Anted =cael Lim Leak Detector. <br />0 Bt4ctrouic Line Leak Dctecter, Model - <br />0 T.,nk Overfill / High-Lrvel Sea=. Modet <br />0 0 her (specify egtllDSti4Ttt type d anodal in 3estictta E on Pace 2 �. <br />0 Ire •Tank GaUOV Probe. Model: <br />D A wider Space or Vault Scnaor. Modd: '— <br />(3 F. ping sump / Trmh Sensar('s), <br />Q F., H Sump Scwmr S). Model: <br />❑ b• ecUniersl Line Leak , <br />0 E e�c}ttr/mwe Line Leak Detector.MAck <br />Cl �Tyi nk Vyaffl / fli . Level '. Mod <br />��� ��°fin p� _ ••••••- <br />0 0 hdr ( ` gUiP� tM Model tri Section E Qat Pwd Zt <br />Dlsp user iD- --U—! _ <br />' b q==Coalniaateut Senwgs). <br />S! .era- Valves} <br />D sponsor Containment Fload(al and <br />Dbp unser rD: T <br />Q D speaser Contac u nw Seasor(sA Muds l: <br />(3 Sitar Values). <br />®D M= ContuiumM Fioap(s) and Claain(s) <br />Dbp seer 1D: <br />Q D s anw Corkiranmt s) Mosel: <br />to S1 ear Valve(a). <br />QDi .oewa Contemment Floaffsl and Chairurst <br />Taelc bi: <br />- <br />q Is-Taak Gwj&g Fmbc. <br />l��lodd: <br />(3 Anutdar Spam or Vault Sensor, <br />Uodel: ". <br />0 Piping SUMP / Tretxrch ScnsaKs). <br />Modal: <br />U Fill Sump SMrsctr(s� <br />Model: <br />t] Mechanical Lim Leak Detector. <br />Modal: <br />U Electronic Line leak Detector, <br />_ <br />Model: <br />Tank Overfill -Uvol &=or. Model: T. <br />Q0 <br />$md model in Section E on Pago Z <br />Tank ]D- <br />0 &Tmk GAU&S Probe. <br />Model: <br />0 Amuilw Space or Vault Sensor. <br />Model: <br />E3 Piping Sump / Trench s). <br />Model: <br />® FIX Sump sa nsor(s). <br />Model. <br />13 MftbW=l Line Leak Detector. <br />ModeL- <br />l�r+,kc�tztmic Leak <br />Model: <br />�® <br />�} <br />Contaittt Srwsor(s). Model: <br />jj� <br />$W*), <br />CI Disoenser Confi"n eat mantra) ,M.a 1-16®:.,1 <br />Dispenser 1D: -- <br />q D*)Izrser CMU&MMA SCMA(s)- Model: <br />0 Shear Vulve(s). <br />Q Containment Flost(s) and Chain(4 <br />i ser ED: <br />Q Dispenw Cantaaipment Sett'or(s). Mads: <br />4 shcmr Valve(s). <br />const= mora teaks or . copy $tis iia m. htcYttdc iafottn8tioaa i� every tart$ Mui at tht ttrcility. <br />C. Certification - T cortlty that the equipment identified is this document was lnsprecwd1servtced In accordance with the <br />nanufactur+ers' guidelines. Attached to this Cettiticatlou Is Information (c.M maunfaetur'xat7' ehecktisty) peM"ry to verify that this <br />aformation Is correct'sud A Plut Ilan ahowIng tke layout at monitoring equlpre For say loqul meat capable of generating such <br />.reports, I have also attached s copy of the t� part; ( alitkM srroo: Stem tytly Alarm ry report <br />Teal nieian Mute (print): dkIlatVt4� rid_%d� � Sign&teuc: <br />Cert ffcation Na.: _ j License. No.: -� <br />Test ng Company Name: •� % � . r" Aj LX Rd JTgdLot-11.._ Pl:ot�e. No.: � cD ! 6 —10 76 <br />Site address: -C a i SOt,+1�, 3QAa V 1A) `_ Dmfs of Testing/' g. � f l <br />bervicirt <br />• Yugo I of 3 Wroi <br />Moi itoring Systeta Certif atioa <br />