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09/13/00 09:45 V2 3 4762 SUSD FAC PLANNft Z002/008
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<br /> O. Box 13059 ampion L
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<br /> i;- P-cecisioa--44g k Testing Sacrarrenlo, CA 95813-3059
<br /> rCA 800-660-9443
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<br /> NEV 800.949-9413
<br /> (916) 927-1557
<br /> SEP 13 2000 Fax: (916) 927-7345
<br /> NVIRONMENTAL HEALTH
<br /> T/SERVICES
<br /> RJ NI G SYS S T-E A I E- U PAI EN'
<br /> Al 0 N � 1 1: CER"17-IFICATION
<br /> Date of Tesii-)&/ServirLng: Facility NaT-,-e:'r,—E7 t�_j;'I
<br /> Site Address: '
<br /> Cizzy:.5�Touo-!D �,I 7;p:
<br /> Fac;1ityContzaPe,-son-aj�� �ntTn C -itact,P�o.ne No.: 10 z
<br /> Contact
<br /> I of'••i cr S.- "Cm s -
<br /> 5 ): _ LocFtio, oCc ,,,of Pane j(s
<br /> !,4ake-,Model of Line Leak Detector(LLDT^ " LLD Lczk-17h;esheld: J?t.* 5!.p.T.-,.
<br /> Complete the fol-lowing checklist:
<br /> Yes 1 0 -.N'O* !Aonitoring system is optr?",b)e sp-ecif-ic?tions?
<br /> `res Q No* Audible alarm is oper-r-rion;j?
<br /> Yes I Q ).Q-j visual alarm is opera"'onal?
<br /> t'Q Yes f 11 No, Monkoring s
<br /> ysiem ;s sc.-wred en W'Ej.- —or_wd tan, p 'n.
<br /> ?
<br /> Yes Q No* For pressurizz d pipL-)-sys,-eT-.:s,do ih-,%:"nes zwo-n2tically shut do\-,-n if,he system de'--
<br /> CI "N/A fails to opt.ale,or is disco;-,,i-.,-,:d? Uyes,which"monilcrincy d'evicesmiliale Po;iu'lve shut-do\N-n?
<br /> it
<br /> 2 Yes Q ",\*a For Monitoring syslerns,-vhich-'erve asLa.:Ik Overfill warming devices, does the overflillwaming function operate
<br /> N/A P,-DP--T]Y? If so,2t Whzt percent of tank, capacity does the Plarm.,
<br /> In the comments section below,describe how and%vheyi be
<br /> Check the appropriate bo3:esfo indicatespecificequipment inspeclecUser-viced:
<br /> Ta,-I,ID No.:12_LZ Tazk ID!t o.: ' ID No.:
<br /> 72ak D
<br /> p.1 TZ.,j C2L:SI,
<br /> U A-- ?wr inuSpar Stm,)r spice`sensor
<br /> -rnpSpxSensor
<br /> t Is r
<br /> Piping Sump Stmor E3 Piping SLr-.p SensorT?-I C
<br /> pr,
<br /> "re
<br /> 'low In-Tail:G-.;.�ging Probe 0 In-TanL Gauging Probe
<br /> 'Sp, I
<br /> .SPCT_Str C0—�probe
<br /> Detector LtLk Dtt.,.or Lz"—Dc',cm, D U,)t L,el- r !i
<br /> U.-,c I-,?j,,Dzzctor Linc"- -DcLzctor :1 E-,: -.-,ie Linc D---,zLi.r
<br /> Comments:-7f�
<br /> I certify that the equipment identified above was inspecfedhem,iccd in accordance with manufacturers' guldelines. Atfacbed
<br /> Io this Certification is information (e.cr, m2ow,-clurer's checklists, etc.) necessary to wrify that the above, information is
<br /> correct and to describe any repairs, replacement,or recalibr2tion of equipment.
<br /> 'FaneOf Qualifled Technician(priw):Wl 111
<br /> TestLw,n Corq'any Name:
<br /> 1phoncNo.: N-00
<br /> L1-036 R cv.0117/37
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