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=794-0102 <br />ACTO, BL. Continuous Monitoring <br />�� �X iC,Zes# 95686 Device Certification <br />524-9087 <br />TEST DATE 3 / y % <br />-a&&-/$8 <br />SITE: <br />OPERATOR C CH� Stwtiunq OWNER <br />SITIC"DRESS ADDRESS <br />ate b <br />PHONE PHONE ( ) <br />., nAnnr, nr MnNITORING SYSTEM _ / !^� <br />onv <br />INDICATE LOCATION OF THE MUNI I UHMI otNavna i CO � cv -I r.....••..+ •� • •-....• • . -- <br />Annular Space Sensor <br />..- - . --- <br />--- - - <br />SIGNATURE OF CERTIFIED TECHNICIAN <br />on torito GTa <br />i i a•... k <br />Sump Sensor <br />*/W <br />Capacity of Tank <br />// Li <br />Dispenser Containment Sensor <br />r- <br />Type of Product Line: (Gravity, Suction, Pressure) <br />Tkr <br />Electronic Overfill / Level / 0707 <br />Ke5 <br />onv <br />INDICATE LOCATION OF THE MUNI I UHMI otNavna i CO � cv -I r.....••..+ •� • •-....• • . -- <br />Annular Space Sensor <br />..- - . --- <br />--- - - <br />SIGNATURE OF CERTIFIED TECHNICIAN <br />Sump Sensor <br />*/W <br />Dispenser Containment Sensor <br />r- <br />Electronic Overfill / Level / 0707 <br />Ke5 <br />Electronic In -Line Leak Detector <br />J -D <br />Mechanical Line Leak Detector <br />T) <br />In Tank Gauging Device <br />tT3 <br />nur_ ov of •rIun a VCC nP Nn IN ♦PPI Ir`ARI F Rn%' <br />Does the rnoniionng sys"am, have audVc and <br />6- �/ <br />SIGNATURE OF CERTIFIED TECHNICIAN <br />Does the turbine automatically shut -down If the system detects <br />a leak, falls to operate or is electronically disconnected? <br />PRINTED NAME OF CERTIFIED TECHNICIAN <br />Is the monitoring system installed to prevent unauthorized tampering? <br />r- <br />Is the monitoring system operable as per the manufacturer's specifications? <br />Ke5 <br />Which continuous monitoring devices Initiate positive shut -down of the turbine? LL D <br />CERTIFIED TESTER'S ID# <br />6- �/ <br />SIGNATURE OF CERTIFIED TECHNICIAN <br />PRINTED NAME OF CERTIFIED TECHNICIAN <br />