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N <br />'N OPJNG SYSTEM CER CATION <br />For Use By All Jurisdiai Wad do the Maze ofCa&fa" is <br />Adhoray Cue& Cfwpter6.7, Health curd Safety Codes Chapter ld,, Di *W.3, RUL -23. CaWo ma l oOdc afRegufations <br />'Y ds foam must be turd coaoc=x=ct=dqgsnd=Vidmgof monitoring equipment. A separate certification er retroat must b --prepared <br />for each monitoring system control pand by the technician vho performs the vrocic A copy of this foam must be provided to the tank <br />system ownctlopeaator. The ownedoperAor must submit a copy of fids foam to the local agency fcgulatmg UST systems within 30 <br />days of test data <br />A. Generalinformatio <br />Facility Names r'7 - Bldg: No - ' <br />Site Addr=: /v !�. ('�,�s/�i- <br />Facility Contact Person: % . K.drr itTnl7 Contact Phoac No--e2(-Q <br />Maicc/ModcI of Moaitociag System / Date of Testitrg/Savici _ �/�(�J � <br />J <br />B. Inventory of Equipment TcsteWertified <br />ChodrtlK.aavanritteholies tofilam a,meaficeaofimeat <br />A In Tank GaagmgPmbc. Model: 'L <br />SpaxorV&*Seas= Mod <br />PipingSump/TwnchScasot(s). Modd: <br />A Modtamiw Liao LakDo,cw& . Model: 'T -- <br />® EloctroaicLineLc*Dcaoctot Model: <br />TastkOvtxfll/EPagL-I,cwelSensa: Mudd: �__ _ t.( <br />®Other(spcdfYogaipmatttypeamdmaddiaSaxioaEoaPa�c2). <br />Tanks : <br />0 In -Teak Ganging Prnba - Model; <br />0 A=xdarSparxorVauitSenson Model: <br />® Piping Sump / Trench Scasor(s). Model: <br />® FII Sump Scasor(s). Model: <br />Q Mechmacal Line Lcak Daticton Model: <br />0 Eiccuonic Line Leak Do=or. Mode: <br />Q Tank Overfill / High -Level Sarson: Model: <br />0 Other (specify equipment type and mold in Soction Eon Page 2). <br />JI1 Lt -Tank Gaws Paaba <br />Mudd <br />til' Spaxa°VwkScasor- <br />M ��. n- <br />.0 PWMgSUW/T=chSeusor(s). <br />Moderw w. <br />® FZSumpSc cKW. <br />Model: <br />Ah U&--LakDaacaon <br />- Modd:.j-Zyt7[7 <br />OIIocft=LineLakDewc(oe <br />Modes: <br />TankOvetfi IrTfi-Iemscirson Model: Cft-J111Ut✓ <br />OQtcc(spoafyt type and mold in Soction E on Page 2). <br />Tank ID: <br />0 In-TwkGauS n ftuba <br />Model <br />® Ananla•SpaccorW ltSewor. <br />Mode: <br />0 Piping Sump/TteachSeasor(s). <br />Model: <br />0 Fill Sump Scasar(s). <br />ModcL• <br />® Mcchanic d I:=- Lcak Ddccwr. <br />Mode: <br />® Elocnvnk Line Leak Detector. <br />udd:® <br />Model:- <br />0Tank Ovafill / ifrgh4xvcl Sc sor_ <br />Model: <br />® Other (Specify equipment type and anodes in Section E on Page 2). <br />D""ispenserI ' 1-b-/✓ Dispenser ID - <br />0 DispauerGc nWnment Sauor(s). Model- a DispauerContammmt Scdsot(s). Model• - <br />'' Shear valve(s). ® Shear Valvc(s). <br />tjj, DispcnsaConuinment Float(s) and Cflain(s). 0 Disvar Conminment Roat(s) and Chain(s). <br />Dispenser ID: <br />0 Dispenser Containment Sensor(s). Model: <br />Shear Valvc(s). <br />Dispasa Containment Float(s) and Chain(s). <br />Dispenser ID. <br />® D'tsp=crConuinmcantScnsor(s). Model: <br />a Shear Valve(s). <br />QDIspaLsa Containment Fio&s) and Chain(s). <br />Dispenser ID: <br />❑ Disp=-Ar Gontainm=(Sensot(s). <br />® shear Wvc(s)- <br />0 DisocnscrContakment Float(s) and <br />Model' <br />Dispenser IIs: <br />0 DispcnsaContainmen(Sansor(s). Model <br />Q Shcar Valvc(s). <br />0 Dlsoenser Gontalnnimt Float(s) and Cham(! <br />•if the facility contains more tanks or disparsas, copy this form Include information for everytank and dispenses at the facility. <br />C. Certification -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br />guidelines. Attached to this Certification is information (e.g. manufacturers cheddists) necessary to verify that this information is <br />oorrec( and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also r <br />attached a copy of the r rt; (thea all ply): System set-uphistory report <br />Technician Name (print)_ Signature_' <br />Li <br />Certification No.: 3b�vry license. No.: O91=1 <br />Testing Company Name: -T'; -,j `P rt-of,�erjg= Phone No.: (E2 Ew- 7 U a < <br />Site Address2,j Z < 'j, rook ��v �,yS�r rt�S c n 3( Date of Testing/Servichng: t i <br />1':�•°� t �-f3 <br />\1<�hhit.�rin_ ��>trm <<•rritii_ttiva ^ <br />