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Oct 19 10 12:07p Elite TV Contactors 12094616342 <br />p.3 <br />Appendix VI <br />(Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at httpJ/www.waterboards.ca.00v.) <br />MONITORING SYSTEM CERTIFICATION <br />For Use By Al) Jurisdictions Within the State of California <br />Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of <br />Regulations <br />This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for <br />each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system <br />ownerloperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. <br />A. General Information j i,, Bldg. No.: <br />Facility Name: <br />Site Address: = ,if City: _ f t r .d .,.o.y!. Zi p: <br />Facility Contact Person: Contact Phone No.: (,�)_ <br />Make/Model of Monitoring System: _� 5 3�-r.� <br />Date of Testing/Servicing:_' !l <br />b t...,....*..,., m Grn dnmcnt TAMadtCertified <br />C. Certification - i certify that the equipment identified in this document was inspectediserviced in accordance with the manufacturers' <br />guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verity that this information is correct <br />and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also attached a <br />copy of the report; (check all that applyr 0 System set-up 0 Alar history report / <br />Technician Name (print): .0 is n--,.:e_.:a -<f -7—. Signature: <br />Certification No.: u'Pense.1Vo.: �` �' <br />Testing Company Name: „i^ <br />Testing Company Address: <br />Monitoring System Certification <br />Pagel of 4 <br />Phone <br />Date of Testing/Servicing: <br />12107 <br />2/21/07 <br />