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01/17/2009 07:13 2098873408 <br />KAREN ARNAIZ- PAGE <br />01104 <br />v n <br />Appendix VI JO/V <br />............ 2 <br />(espies of Monitoring System Certification form and UST Mon(lossng Plot Plan availableat ; ..•.. <br />of <br />MONITORING <br />SYSTEM CERT119CATIOW <br />ForLlOe ByAJ 1 ft a* of cawww <br />AutT OnW Cfteef: Chaps 6 7, Health arras Sef+e~ty Cradle; Chapter 16, Dhdafort 3, TX* 23, Cal fiomfe Code of <br />Reguladws <br />This form must be used to doer tam and s ewidug of r amloft equiprnant A separate vertTicetion or report nV^t be prepared for <br />each monkormg system catbol panel by the taadwmd an who perforwo the work, A copy of fhb farm must to Provided to tele tank system <br />ownertopas<atot. The wwne0operator rrtist subarid a copy of DO form to the local agency regWaft UST system wtt M 30 days of test date. <br />A. Generallnfermation <br />Fadelty Namae: Ar <br />Bigg. W- <br />soe Address: 444 Mosadaie Rd <br />Car: z#�: 95330 <br />Facuky Cont Persona: <br />Corgard Phorm No., C 1 <br />MokeModed of Mordloifrig "am: TLS -350 <br />oateofT 1 1 5-23-11 <br />B. Inventory of Equuipiftnt TesWd/C*dW*d <br />CWA gS amyoride boxes to kndkafia madft eaukrawA <br />Mao <br />Targe ID <br />A In -'!Tank GaugirW Probe. Modak <br />kv P wba. <br />7MAm-udw <br />x Annular Space o Vault Samson, Modak <br />cs or Vault Sensor_ Modst <br />v Piping Sump / Trench Se nsor(s). Modet: <br />E Tnumh Sensor(s). ModelFig <br />Sunip Serw(s). Model; <br />MadeL <br />K Mocha nhw Iran teak Defector. Moder PA <br />R Madmakmil Lane leek Deleckw. m dot <br />Elechwir Line Leak Detector. Ntodst <br />Eledronk: Line Lemic Delloallor. falodak <br />Tank Ona ill t tWha erect Semsos Model: <br />Tank OWN"/ ttWLetlel Sensor. Modem <br />and In &action E on s <br />Tank ID: W4eSel <br />Tattle D: <br />■ to -Tank Gauging Probe. Nl dek <br />In TadrGseging Pwbe. Modet <br />Annular Spwe or Vaull Sensor. Mo" <br />M Arawktr Space or Vault $enw. Model: <br />as Piping Sump f Trench Seatwa(:4 Modek -- <br />SUMP I TMKh SeMam(s). Model: <br />Fdl SuFM Ssn sw(s). Modst <br />3tit <br />MectlarlW Line Leah Modet:. . <br />MFill <br />adaaalbbtsetoe Modet. <br />Elac ago Line Leak Deieckw. Model <br />s <br />Line Leak Detector. Model: <br />Tank Overfill E HWW"W Sensor. Modek <br />Tam* OvmAD F F1igh.t vv9f Sensor. IYltodet <br />am model M Section E <br />08wer Ogg == troe and modal in <br />ISspenser ID: <br />Dbpmw ID: <br />K Corderrenenf senerx(a). Hato f: <br />aS Seaaor(s). ModelZVO <br />R Shearvalre(s). <br />ra Shew <br />r Caanai <br />oftsad OEM. <br />DispensertD: <br />Dispenser 10: <br />xCor"nvrwerat Sereeor(s) modst <br />Senear(®). Mtodet AYU <br />at Stww Valve(s). <br />r Sfevaar Va to ( <br />Pin"ser 10"d M" ands . <br />In r s . <br />spaer ID <br />Ai W: .M_oda�t <br />• akhmeSenaoa). Moder <br />DkPMWWardS.....__.....).. <br />• S "s). <br />StIWVaies} <br />Dispenwr Aotrlsionmil PA)Ws)wdCZwWs <br />Isercontakervent phraw and <br />Ifft faoik'Ltr condeffm mom tads or copy fomn, knokrde Wwmallon fore irwy took and &spsaserat gra <br />C. Catrtff cation - I cuff that the a at Wen0led In Oft doomwN vAw Inspectsrvicea! in accordance with On awradecuffers, <br />guidellnem Attached to ff%% C:eMention Is Irdortnason (&4. ) necesmy to vett recd 03 IrMormatfon is eon*d <br />arcs a Plot plan showing Ute Layout OT wwrinwing a"Fnent. tact ant egos mw cap" orgenermv such reports, I rave also attacho a <br />copy o'f:ha report; fit as vW Systailf a M4* Alarm repon <br />Tecimkcan Marna (pests): Gavin Wiffams g <br />cedwrAdion N,: 1CC# 801628"T t moss!, Me; CSLB# 856711 <br />Teaft why Neow, Henderson Maintenance Company Phone t4m:( 209 ) 467-7573 <br />TeWhv mepany Aftm.. PO Bou 31325 Stocldon, CA 95213 Dab al' T f 5-23-11 <br />kloratorin►g System Cerhfitafmn tie 9 of ` 12W <br />2/21/07 <br />