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MONIWPJNGSYSTFM <br />For Use ByAgJwisdiaio.s WML-, the Sxk of CqbmLa <br />Auchorky Cited Chapar 6.7. H42M 4=dSqf4qy Cbdr� Chq7mr 16. Drwswa 3, 71 -de 23. California Code 4Regutadons <br />This form must boused toaocumultesdogad=cviciggef moniodogequipment ,&MMk-omdficgu6onor=29 mustbear-ena—red <br />for each monitoring mMm contml panel by the tochnician who performs the wo& A copy of this form must be provided to the tank <br />system Ownedoperator. The ownedopeacor must mbn* a copy of this form to the local 8900cY 109dating UST systems within 30 <br />days of test date,. <br />A. Gemerml <br />Facility NaEnc: <br />Site Addr=. -A <br />-1 - <br />NW-Wffl- ffl=WA <br />M <br />Tax & M.- <br />0 W-T=kG=%iqgftab�--' Mod& - <br />0 A=u1ar;SpaccorV=kS=,x. Modd: <br />Q PViqgSutV/TrwchScnso,(s). mod& - <br />C3 Flu sump scasm(s). hio&E <br />Q Medhanical Line Ltak Ddooctoc Mod& - <br />0 E1OC(r0niCL*LcakDdccM ' M*d&- <br />0 Tank Oeafill / NgWxvd Sensor. M*d&- <br />DapcnscrG=ta=t=&nsoK:s). Model: <br />Shear valve(s). <br />-DiVcnscrGontauun= Roat(s) and ChaWs <br />tl <br />P.-MME97f Ira,, <br />model insow(MEOtt <br />T=k M. . — I <br />G b-T=kCAu&gftOc- . � I Model: <br />13 AwulzrSpaceorVaultSen -Model:oc Model:Cl PipingswPITmacbscasor(s). Model - <br />0 FA Sump Serrsar(s). Mod& - <br />E3 M*ch=k.dL:M-Leak Decoct: Mod& <br />0 Elomodc Unc-Lzak Ddwor. Mod& - <br />Mode: <br />G Other(specifYowipmcat twe and model is Section Eon Paec21- <br />DispenscrContaintnent <br />ShcarValvc(s)- <br />Dispenser ID: -- 5�44 a L 'Dispenser ED. <br />11*DispcuscrGontainnicnt&asor(s). Model: 0 DispenscrOontaimnentScasor(s)- Mod&- <br />ShcarValvc(s). <br />0 Shear valve(s). <br />1?Dispcnscr Containment Float(s) and Cb2in(s). - 1 0 Disperser Containment Roat(s) and Chain(s). <br />j <br />j Ls <br />penseriu- Dispenser ED. <br />DispenscrGontainmentSmsot(s). Model:0 DispezerContatntnen(Scasor(s). Model: <br />Shcar Valvc(s)- a Shear Valve(s). <br />OlDispenscrContainment Bog(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s). <br />-,if the facility contains nxft tanks ordispensax, copy this form. Include information for every tank and dispenser at the facility. <br />C CeWfiC26011 -I certify that the equipment identified in this document was inspectedherviced In accordance with the manufacturers' <br />guidelines. Attached to this Certification is information (e g. manufacturus' cheddists) necessary to verify that this information is <br />correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also <br />attached a copy afthe qMV4 ITSystem set-up history report <br />Technician Name (print): Signature -A <br />Certification No.: License. No.: <br />Tc -sting Company Phone No.:((, B x vs 0 as 0 <br />Si(c Address:2 17 r (-V� ojS 4A 9(6br;5' Date of Testing/Servicing: <br />-f 3 ecimr <br />