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HWIN AdWPLIH '61 '11r ;W1j P;AI;D;� <br />Appendix V1 <br />MONITORMIG SYSTEM CERTIRCATION <br />For Use By All Jurisdictions Within the State of caufarnia <br />Aulthodly Cited. Chapter 6.7, Health and Safety code,- Chapter IS, Division 3, Title. 23, Callfamia Code of Repiations <br />This f8fm ~ be used to dovuwownt testing am serv"monrepent <br />of flAwing equipment A separate carillication or n8p <br />aach monitoring sptgm wMrol panel by to %chnIclan who PWOMM the work. A copy of this farm FyNSt be pray art mud he preoe.�. <br />dNh*irjbp*mfwr. The owrAdopoteW must BubmR a r �Aded to the tank "am <br />espy of this to"n to the Wal 2yerr <br />'Y mgullkling UST sysisma wmrn 20 dap of fiestdate. <br />'T r-41' <br />Fwft News: <br />—EGG"N MR WART <br />trie Adjr4as: 1997RY03wrrE City: MQ*M- zip, <br />Pwilwtuftatpentang, BILL Qwftct Phone: Nq,; P-091 89s Hsu <br />WkBOMadcl Of Monitoring System: AU JR 4 Data of 7"fing/Servid"T 12-1-Nia- <br />0. lnvwftry of RquipmentTestedleer"Od <br />CI p,* the 800 M RFWe boxes to &jd icute sna nFfiff! pf,"Inm <br />87_ <br />- <br />Modd.NAce <br />09 ]A-TEMIC OR49140 Prabo- <br />Model; MN <br />ITankin, <br />0 Annuler 60906 Or vault Sensor. <br />Model! ULS <br />10 PWr19 SUMP I Tiunch "FIGOI(0), <br />MOM.- ULB <br />13 Fill sumpse6zcw(*), <br />Model; <br />0 Mechanical Umv Leak Datecter, <br />Model: RED JACKET <br />Al Elecbvnk Line Leak DOWotor.. <br />MGM -- <br />0 Tshk OWO I klgh-LeW Smor. <br />"adat r-LAPPEg <br />0 ogres (wv* "U4pmrlt typo -A Model in Section E an page 2, <br />Tar* RX. <br />Modd; <br />13 In -Tank coboino Prem. <br />Mid <br />Ej Annular space or vauk Sensor, <br />. . Madet <br />13 Piping Sump 17`r*fich son", <br />Model: <br />13 Fill Stow &wWr(s). <br />Model. <br />0 111160ftnitalLin4l-ahic Door. <br />Model! <br />14 FIOMWID Wnb LedkDetectr. <br />Mord: <br />C3 T -k OYWM / l IWLevel Sensor. <br />Model. - <br />0 Other (spalzity i!quiprfient type ang alodul in S-A- R 00 Page 2). <br />DkPenwr VD: 1-2 <br />made,: ULS. <br />0 <br />114add. 'ULS <br />11 Shearvwvc(s)_ <br />Dispenser ID: j.8 <br />0 Di3pamereafminmontlFlost(a) and <br />0 0j5panaer Containment %"*Or( q), <br />Model! 41-S <br />N 0L9paqW COtneinmeittSeatsot(e} <br />Madel: U! 8 <br />❑ blipenser CDmahm" Fknt(s) ana Vhajn(s� <br />n M::=W and-cilaInK <br />'Ll DspermwComainment <br />Q191)" ter CwWrtrApnt Scnsoqa <br />M"jal- <br />13 &-wr vw*q� <br />ment Pjo%qaWW (;Wifl(i). <br />Tank ID; 91 <br />to -Tank Gauping Prim, <br />- <br />Modd.NAce <br />Annular space or VaunSensor <br />M040); <br />Piping 156mp / Tromh 3.naor(a� <br />AULAS—� <br />Model. ULS <br />0 FM Sump sensor(q). <br />Ma"! <br />J4 Mechanical Line Leo Detector. <br />Modelt. 3wL'0cXE-r <br />❑ McclsonkIL(ne Leak Date". <br />Model: <br />^rat* Ckwffil / Higb-ccuri sensor. <br />Mocick FLAPPWK <br />❑ cwneqspcc4 equipment Noe and mow In soction r on P.Ma 2)), <br />Tank ID: <br />❑ (ft.-TO)TR Gauging Probe— <br />Modd; <br />❑ AW.wlar. Mpnqx? or Vault seh!5ur. <br />Model: <br />❑ Piping SUMP/Trench Sensor", <br />Model: <br />Q 'F;'M Sump Sen3o ro), <br />Model: <br />❑ M80hanical Lino Leak Dalee*. <br />Mode)!., <br />❑ Electronlo tine Leak Dstecw. <br />Madel: <br />tl Tank Dvcrffl / HGNLGvgl UnDOr <br />Model: <br />LEI, Oth-(apactilly equipMort type and WWW In SaedatEonpS992). <br />FDISpsMf�-ID; 3�4 <br />0 D"crGontainmentg"ear(a). <br />made,: ULS. <br />®.Shear ValWa <br />❑ 10J500hoor Containment Float(e) and Qfiain(s). <br />.I ...... no= <br />Dispenser ID: j.8 <br />0 0j5panaer Containment %"*Or( q), <br />Model! 41-S <br />❑ blipenser CDmahm" Fknt(s) ana Vhajn(s� <br />'Ll DspermwComainment <br />8*00 <br />MO&V <br />Q-Dispertwir contalntnint ma and ch <br />C. QwWwatilon, i certify &M the 01111WIDIFIGM Idenk"ed In this 4ocumient vim [p&WtqdAav%jcW In EMOOPO", with the'Wanufactwens, <br />fluldeline& A#Adhed to thL$ C06II411111111011 is In1fmM1U0n (eO thaftfactureW cherklieftj neceBoaffy to that this immouts, Is cand <br />-d a plot Plan "0*119 the 1181FOut OtIM91111160finfLequipwont For any a "tj mff&oetpaWa#Mqnq verify <br />avvium Betup El Alarm history report radrtg sUah MPOFIS, 11114" 4W alttwbadl a <br />Temll"iciin NOM9 (1)"0: FELIX RAMIREZ <br />Gijasture, <br />certIllmdon No.: 62D6 <br />Testing ConWartir I" N� . 0 40 <br />Name: AFFORDA-TrW Phone Na, <br />A9 744-0 3 <br />r -"g CMWY Address: 416 TGA CA 9S6s2 <br />Date c1TcsjhWaermW, <br />cWtlficatton <br />Palyi 101`4 <br />M1107 <br />wry iN� 3 <br />H- <br />