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Nov. 2. 2004 10:33AM K R ENTERPRISES <br />N o , 7 2 6 6 P- 3 /' <br />MONITORING SYSTEM CER'T'IFICATION <br />For Use By,41ifurUdk*ns Within the Sine of CalPrMa <br />Agahorio, Cited: Chapter 6, 7, Health and Seery Code; Ckapser 16, .Divkian 3, title 23, CalVomia Code of)Uguledaw <br />This Porn, aw be used to docunwnt meOng and mvicia g of monitoring equipment. <br />by the toohnici9n u/lto PWfOnim the work, A mpy of 071a fin must be provided to the tank <br />cyst= ownu/operator, The owner/opesabor must abniit a copy of this farm to the basal ag=y rcgulaft UST 6yorm wift 30 <br />days of tut dace. <br />A. General Wormation <br />Facility NUM: <br />Site Address: _ <br />City. <br />Bldg. No.: <br />._._. zip: <br />Facility Contact Porsoa' Contact Phone No.! ( <br />Make/Model of Monitoring System: yeec(eY- ml_ Acte ofT Semvwflir. - i—Iii.e-tt <br />C. certiftakdon -I cert* that tho egatpnmut Mentifted In the mvlced is Ofteftdoo with tlwe mn ' <br />guidelines. Atmched to tm Cjwdfiengfep k is a (e.8. omfectursers' ) nommy to tnttly that dds im0brownflom is <br />cwrect and a Plot Me sbcwW& this layout o4 t. Ser MY WdP1DW 401FAW OfPSOM91018 alma reports, I have also <br />sttaehod a copy M the rc; self, amort t ): OSY00k Ut-Up Q A&M biaxo �tcat <br />Toohaiclsn Nam (print): a M Sivaturre ..••� <br />Certif cadoa No,: Limmee. No.: <br />Tasticg Cotnpatty Nates: ,,,, a t; azrQ r� � (,�,,�6�'r ...- --- - now No. :��) <br />bb'e� ?0 <br />Site Address: rwe of <br />tnr-ens -14 Page 1 of 3 NOW. $&"*I <br />