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MONIT04ING SYSTEM CERTMCAUW <br /> For U41WJurirdiaions Within dieStateofCalifornia <br /> Authority Cared-Chaprer6.7.Health ety Code.Chapte•16,Diviaw3 Title?3. Cede of(Regulataoras <br /> This formmust be used to document Gating sad servicing of monitoring equgnneat•A separate certification or rwo must be nn^r.a.=-.v <br /> for each monitoringGs control panel by the technician,who performs the wak. A copy of this foam mast be provided to the tank <br /> systeaa owacufoperaw-•The ownedopaaW must submit a copy of tfhis foam to the local agaiey regulating UST within 30 <br /> days of test date <br /> A. General Information <br /> Facility Name: v r ,� / Bldg.No.: _ _ -- <br /> Site Addtnxs: "t �7 r C - <br /> -- _,.__. .�:..,- �✓. e/r=.� -ey qty: <!•Y*'� �C— <br /> .: <br /> Facility Contact Per$= Contact phone No.:( 1 <br /> MakdModcl of Mocator-wg systeac rG S' 5s5 x' Dace of Tes<ing/Scavcciag: �(p___/�2� <br /> B. Inventory of Equipment Tested/CertifiedJ <br /> Chock we a bones to Indicate . <br /> Tank ID: Tank. <br /> �AsmdarSpaoa« tnkSaesx Mold: ✓ � TaokGa�loCaba. Model: � <br /> JPipiagSump/TveachSatsoc(s). Model: �aad' Spaoe«ochse sw(s Mudd: <br /> WSCOSOKvOm. ksmw <br /> ❑Fall Sump Saua(4 Model: ®1� M /TrandeSatsa(s). Model:_ <br /> Model: <br /> A—Madwilcal Line LeakDaActor: Model- 1-,Cz, SLS L eL *DdocW <br /> _ . Model:_ �aC <br /> ® LmeLeakDaeam Model: 0 Etocftv=eL2wLcakDda=t Model: <br /> 1ffTmkOviaO1Igh 4AVClSewAr- Model: OvCM1 tigwj-dSensor Model-, <br /> ®Od menttype and model in Section Eat ®Other( tad model in Section E as Pap2. <br /> Tank ID: y ITanlcIIk <br /> In Tank - gtag Probe. Model: <br /> Gauging Probe. Mold: ❑In-TeakGau <br /> Annular Spam orVault Seasa Model:/ d ®AanaIarSpaoe«VaudtSens«. Model <br /> Piping Sump/Tcahch S«nsor(s). Model: 9 ❑Piping Smnp/Tranche <br /> Q <br /> Fill S (s). Model <br /> ,�• Sump S�e(s)• Model• ®Fll Same (s)• Model: <br /> Mechanical Line Leak Detector. Model: i)�� ❑Mechanical Me Leak Detector. Model <br /> ❑E cwonic Lane Leak Detector. Model• ❑Elcctm a Line Leak Detcctor. Model: <br /> erTank Overfill/lfigh-I.evd sauor. ModcL_ w his y/y ❑Tank Ovatill/ Sae«. Model: <br /> ❑Other(s ui a in E on Pa r.2). ® ( in E on Page 2). <br /> Dispensa•ID: RkenswID: <br /> Dispenser GontalnmattSaeso(s). Model: &dsor(s). Model ✓� <br /> hear Vaive(s). .S ShearvAve(s). <br /> ❑ D Containment Float(s) s. ® Con"kment Floats)and Chain(s). <br /> Dispeacur ID: 'Dispense,ID: <br /> ispeau ntaiamcnt s). Model: 6 ❑Dispenw Containa«at Sensoe(s). Model: <br /> Valve(s). ❑Shear valve(s). <br /> ❑ D Containment Fioat(s)cad Chaia(s. ® Coatainmant Floats and s. <br /> D•ispeaw ID: DispenserID: <br /> ❑ DispeuscrContainmentSensoa(s). Model: ❑Digxn= Seasoc(s). Model: <br /> ❑Shear Valve(s). ®Shear valve(s). <br /> ® 'f l2 s)and Cltaan(s• ® CwtanuaattEkM <br /> IS1 and Chaut(s. <br /> *If the facility contains more teals«dispensers.copy anis form. Include information f«every tank and dispa=at the facility. <br /> C. Certification-1 wx"y that the equipment identified in this document was Iaspected/savleed in accordance with the manufacturers' <br /> guidelines. Attached to this CerOcatioa is information(e g.taaanu&c:teu+ers'cheddists)DeOeMUto verify that tilt information is <br /> eornecd and a Plot Play dwwfag the layout of moultoting equipmett. For any pmeat a4able of genera rghocts,I have also <br /> attached a copy of the all brat aPPIyY):�,✓ ystem set-up . <br /> Technician Name(print): it./° Signatu <br /> Certification No.: eoejS�Jy Ucenm No.: ®.Z <br /> Testing Company Natnc:Tr.r~�, »ft+rn nm •� Phone No--(� <br /> Site AdditSS:',, $�-�' ..Z._t arltL OU�., ���r�n ,ak e� 9(SOu 7 /j <br /> i:1--r i<d3 ulnae <br /> \tunit.riu_�.a�en Certifcation•,•,,,. <br /> . ... `:'. ] ..- .':;4. ty' ,„lyP4b-wrG.'�na.4`'#„°f4J� ..^wi�,:F•'Zw.�R��s�� 90(:::`x^: ._. <br />