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d <br /> MONITORING SYSTEM CERTMCATION <br /> For Use By AM JarbActions Within the StateofC is <br /> Aut Cit 6.7,H 1 3, a 2'3,Cal#brniaCoals ®ns <br /> TWs form most be used to document testing and of A separate certification or ran=m <br /> ft 9@A g system control Dand by the technician who perform die work A copy of this form must be providedto the tank <br /> system /operator. 11w owner/opemw must submit:copy of this form to die kxW agency regulating UST system within 30 <br /> days oftest date. <br /> A. General Informatiou <br /> Facility . AL&±—h l- Bldg.No.: <br /> SiteAddress: gGt '�; 1�-- 1J i c-f-Ot A c Zip: <br /> Facility Contact P oda Conhict Phone No.: '7 171!�µ <br /> Make(Model of bloultoring Dft offestingffievWchW /0 <br /> B. Inventory of Equipment Taift&Cerffwd <br /> T TmklD- <br /> • <br /> T In-Tank <br /> • Annular Space or V Space or Vault <br /> Piping• /Trench SensoKs). Modek U Piping Sump/T s). <br /> Fill s). s) <br /> Mechanical l: <br /> 13 Electronic Une Leak Detector MM& El 1310001&Line Leak Deftctor. <br /> T /Iii Tmk Overfill/Ilighr-LeM San=. Model: <br /> WifMIM MM and modelin S on Page 2 in Section E on Pasc 2 <br /> Task W. TsukW. <br /> hi-T In-T l: <br /> C1 Annular Spam or Vault or Vault Sensor. Model: <br /> 0 Piping Sump/T s}. S /T s). Model: <br /> Flu S s). Fill s) <br /> Q Mechanical Line L=k . <br /> '-': Modek 0 Mccluinical Line Leek Detector. Model: <br /> . Electronic Line Leek Detector. Modek <br /> T /Hi T 1/ <br /> 0 Other(specify equippent type end model in Section E to, ' 2. <br /> Cl Dispenim Containment s). . 13 Dispeaw Containment Sensorft <br /> 1A Show v s). v s: <br /> s s <br /> s <br /> s <br /> Dispenser W. -7t- Dispenser ED: <br /> D t s� Containment s). Modeh <br /> aShearVs). valve(s).hear <br /> 13 RUM=Contaummut s s t s s <br /> M . <br /> ' s}. s). <br /> 03 Shear V s). vai s <br /> jM Containment s s s s <br /> •Ifhdft contains nwre toob at dispensers,copy this form. Include influmation for every tank and dispenser at the famlity. <br /> C. CCrtiftatiOn-i wft that the apiputent Identified in Mis docutawat was in accordance with the vasnaftetoreW <br /> guldellum Attached to this CortHication is hArmation{ ' } necessary to verffy that this infwatation is <br /> corred and a Plot Plan dwwIng the layout of noultering equipinent. F of generating such reports,I have also <br /> attached a copy of the repw 4(cbwk aff dud apply): p U Alarm <br /> T ): - _ _ Si <br /> C o. / aILL u o. 47 <br /> [ 7 <br /> Testing CompanyN 3 <br /> S' A CO7 ,<. C f�c 9S` oT ,g: C /31 /6c <br /> Page I of 3 03101 <br /> Monitoring System Certilleadou <br />