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e CALAVERAS EMI j�AL17i <br />UWATIONAPAGE 01 <br />01102/1995 63:27 29975 5 22 <br />_ ®€ <br />! S STE _ j <br />AurhOrfty Cued:1 Chapter 6.7. h a'.rh an.4 S4#0 Coo'e: Chapter f6.1}ivtsie7•n J. rifle 13.,Califomta (OQY ar Regulataans <br />etiL . If more than Opp- <br />INS <br />rae <br />INS form must be used to dc: wiment testing and. servicing of as+ tcncertiotcaitgoti ar mint must f4>C <br />monitoring system control panel .s installed at the: facility, a of thus form must be <br />each monitorinfl syst cenrtml. label by the lech nician who perforans tyle work.. A copy <br />ppo FF `ed to the system Ow c:•(apcx-ator. The owner! of xinust submit a copy of this focal to the local <br />ar eacy reguhatiwag UST systemsInstructions <br />arc printed alt the back of this page. <br />41hin 30 days of test date. ' <br />A. IGeneral Informadou <br />� � ���yj�� Bidg..No.•. <br />Facility Naas: f <br />Facility C t Pelson: <br />Z<Z) DTT <br />Coutact No.: t • �_�� 2 ` <br />lvtaWMod l orMonitoring Sync= p <br />�avtnt+st`yo1fFigUlp tsttt l:d/Ccrti�ed <br />Nny 02 9nI <br />B. <br />(>wecktExe afro rrfate bo=a to Ind �I.cs n meat.has serviced: <br />Li Taal: GanB Id d:t: Q' bn• attalc Geaugittg Probe. Madel <br />t lo: d -.L O A lot S OW V i s <br />S C* Vtwlt w w <br />£i. S etach s <br />d Fi a Flu s 5 s). . <br />C1 l Lease D l� Ad: a Meeh _Liae;Lcak Detector. Headed.. <br />C3 E L Delmar. :` Wet: 0 $le�ouie Line LeakModel <br />Q Tanis ll IH Sensor. h: )deet: Q T Jaftgh Model: <br />Q J s). h A a l:' Cl D' S s).. Madel: <br />Q S."I Valvc(c) CZ . V s). <br />D t) , Flows) and ( ea sn(s}. sand s <br />d col er f ui t abd teI in Section E on P•i e _ . C3 .C3thea ei and taodet ett Stctiext E em Pae[e ? . <br />Tania ®: _ TAak 237: <br />Q ltd Tweak G $ Cl lv=Tank Gauging Probe. Model - - <br />p A Scor vault P. octal: Q. Ane:talatSpneee>r Volt Ssxesot• Modes: <br />ranch Se:asar(s). t• odiel: Q Piping rcnch. s)_ Madel: <br />® Pi�ing.Sami Model: <br />C3 Fall Sump s): ` F, o+IC i} Felt Ssttas¢ Seaasor(s). <br />Mechanical Line Leak Praetor. I s»9cl <br />13 Mechanical Lias Leak [ktee car. Model.- <br />Q " <br />4 El' is Line Leak De temr. 4 6 w- Cl 6knsonie Lase t ease Detextot. Iltc>det: <br />Ci Tabic Overfill /. Hi Levet Semsw. Model: <br />Cl T t?vaxf:lt i High -Level Settlor. i o fel: t3 Con ' w t Sensor(s). Model - <br />{j 'yam Can, <br />Q vatvc(E). D Shtw valve(s). <br />i3.;tJupenren Cex+ t Fivat(s) utt! h:�ist(S). O V Cat , Rows) znd Cinasre(s). <br />Q Ottxt ( i ui d rr do.1 in Section E on Part 23. t3 Other teed model in Scotian E an Page 2).— <br />:C. <br />:C. 6Ct ' cadon - i certify tier ` t be equipment identified In this, doetunent was Wpectedlservlced is accwllaucc with, th4c <br />, foclurers' checklists) necessary. to <br />' }na . eel. latched t4 this Ce:t•itlttcatfoa is iaf ou (e$. <br />verify that ttW jimfortmtJon kcoat reel and a Site Plan showing the layout of nionifaring equipmcal. For any equipment <br />capable of gener6lng such re, orts, I have alto attached a copy of the (check alt that a ): ®. system set-up irclagrt; <br />0 AlUm_; rL <br />y eiaa N ): f E � , Cerc/Lic. No. 4i" <br />Ai" <br />Co i+l tj` i ii[1P tl � Phone No.. ( <br />�'e jr, <br />JestingComp <br />