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Work Order: 2250417 <br /> MONITORING SYSTEM CERTIFICATION <br /> 1+`ar Um*Aft Jwthe Swe Of "d <br /> Atuhority Cired.-Chapw 8.7,Health and Stpre�ty Code;t:haprer 16,Division 3, a 23,Qdt0rnfa Code of <br /> Regukrfiow <br /> and servicing of mond0ft eat certifi ' r <br /> 71ris font must be' to testing <br /> by the the tcdmldwho perfomu the work. A copy of that form must be provided to <br /> nre�r d f each mm'+toe 3 systu° ! mut submit a copy of this form to the local agency regulating UST system <br /> the tank system owner/opa'atm'. The over ./vp�atm <br /> within 30 days of teat deft- <br /> A. Genemt Inform -on�-� Pf ZQ��4 � Bids•No- <br /> Facility <br /> o- <br /> f city: hg*f f <br /> FacilityIName: he.+_ Zip: <br /> Site Address:__ —.-- contact phoue Na: <br /> Facility Contact PersAm: 6 / Z Y.�o <br /> MakwModel of Moaitoriag System _1-2:0 flea of T suiting �__. <br /> B. Inventory of Equipment Tatg&CtrtiW <br /> Checli flee x loses to taakate weelfie 3=90 <br /> r .M Teak ID: TZ <br /> Took M. 1• p.np &�-Ttmk Ftpbe. Model: tPY63 4c7- /G�1� <br /> 0(jn-Teak chagg t►a Probe' Modck 4.t 3S a-Y 1 space orVta�swoor. Mosek -4 44 <br /> �[ space or vauk Model:- /Trench a} ?4Y 80 -Z4E <br /> $amp/Tram :iR�NIS -1zc 4T; <br /> Pon q Fill Star>g sawrol Model: <br /> Q Fill Sump Sensor"). Mom Q Mechavilcal Lite L k - Mod*. <br /> ® untynk Mee (y8 . LineLcalc <br /> GElectmaig Lim Wit Dde=r- Model: <br /> Tank Oveefiu//Fligla-1 +i lases: E ca s Q o (D Task Overfill/ typeand model to$ersim B oa <br /> O Other( and Model in Setxioa <br /> Teak w. <br /> Tank 11}: Model Q brTolk Ft b& Model: <br /> O IttrTank O F►ube. Q Anwar$pate ar Valsh Sensor- <br /> D Aratdar Space ar Vauk Senor. Model: ® saw/Trench S=WD*s Modal: <br /> O rpit$tarp►/Troa b SM094 Model: O Fitt Smp sk Mode: <br /> Q Fill sump Seuam(s). Nlode:- <br /> O <br /> Q Meebealcol line Lank Dates a- DdVCW Modek <br /> Line Ledo Q Ekc#onk Lkto Ledt <br /> O Q Teak 0mU d $-eor. M°d°l: <br /> O Took Onerlm/mak- 0 Othercad node in Section B on pop 4 <br /> O Otka and = in S Aida fi an <br /> ID: ' Z iDc Stasor(a) Model: 4 ofDbpenosr <br /> '� Modal: :;80-2 09Disperma <br /> �fK Dispenser Shen YalneEal <br /> yt Shear Vaha(s). Flm�(� Chiat$s p3 • Fbae(a and a <br /> ® ppx_ -a- <br /> a s Model• �9Y? tis-- 2-01 Dispe ace s). Mode: �4Y 3 <br /> me )' Shm Varix(s)L <br /> Sherr Vaive(s). Q s and Cba�(s). <br /> Condprocat a and C haws. <br /> ter. <br /> Alap YL1 O s� Model• <br /> (]> s). O Shm ValsrcK <br /> 0 Skase Vd*s). s O FloWS)and s- <br /> O C mewFkad(s t festa laehtde iafaanaeion for every leek and d d fatuity. <br /> •lf the fatality eontairn tame looks or ` peed ze oceordsm nick tM <br /> C. CertifielltioR - 1 tardy that the egaIPmtat idcatiftiaa We doeutaeat was iae� <br /> asaaafattar�ers'eheek)kso)necemary to <br /> • lly that <br /> this <br /> ,agaidelkte� Attacked to this Certigcadan b infennstian(eg is such <br /> oat of monitoring 2�� <br /> ot. For any aga�r_atea�t capable of generating <br /> information(s correct and a Floc lata showing qts layeat <br /> tii� _ stem p, Aka history rqw <br /> reports,I have also atter espy of r�+reparq 1tiG4 Si <br /> pati <br /> Techrtittan Nie(prig �.�A&t <br /> /Q [ /3 License.No.: <br /> Certification isle.: No.. �Z r"• .5"3/- '�S.f"� <br /> Tag Company <br /> Date of Tattinjosavicinx— �- <br /> Site Address: <br /> page 103 <br /> B31ar <br /> Tanknology Inc. 8501 N.MoPac Expressway,Suite 400,Austin,Texas 78759 <br />