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07-14-03 11:08am From-TAIT ENVIRMNTAL 714-560-8237 T-306 P-02/06 F-203 <br />MONIfORING SYSTEM CERTIFICITION <br />For Use By All Jurisd1l Within the Stare of Caftforn' <br />rx1a <br />A uthorliry Cfted,-: Chapter 6,7, Health 4ndSafity Cridd; Chapter 16, Divkion 3, Title 23, Calll Code of Regulations <br />ffNnMTTM=M <br />A. General.] <br />Facility Name: <br />IMRF�Vm <br />lTito4Tq-wujq=nt. A sep4q., <br />City; Zip: <br />-1�111 <br />11111� j,- �b <br />011 <br />11 �� <br />I <br />Make/Model of Monitoring system:Date of Testing/Service: <br />114. Inventory of Equipment Tested/Certified <br />LIPA llil <br />D's enser <br />0 <br />'rank ID - W <br />ZDispcAscr Containment Sonsol Model: <br />i Valve(s). <br />nk Gaugino Probe., <br />Model, <br />[JIn-Tank Gau&g Probe: <br />Model: <br />lar Space a Vault Sensor: <br />Mol <br />91painular Space or Vault Sennor <br />Model: a <br />g Su r ne sor 9 <br />Model: 7- <br />Ci�Ktpins SurrlplTmnch Setisor (s); <br />Model: .7 <br />ump Senso r (s): <br />Molt <br />[jFjlI Sump Sensor (a): <br />Model, <br />00 anl Leak Detector. <br />Model; <br />OMechanical Line Leak Detector. <br />Model- <br />lectrunic Line Aak Detector <br />Model, Cz. t7:z <br />i [3VIectronic Line Leak Detector <br />Model: <br />arik Overfill/H gh-lervel Sensol <br />ModeL <br />ElTank Overfill/High-level Sensor: <br />Model; <br />�ther. SDecify a6ul V -dclta-Beoti�s. ..� <br />L30ther, Specify equip, tl <br />D's enser <br />0 <br />Tacl ID: <br />ZDispcAscr Containment Sonsol Model: <br />i Valve(s). <br />Probe: <br />model: <br />M -Tank Gauging Probe: <br />Model: <br />Vault Sensor <br />Model: 4,P -T <br />OAnnular Space ot Vault Sol <br />Model: <br />h S=sor (8); <br />Model: <br />�7 <br />C3Pipin& Surnp4rench Sensor (9). <br />Model: <br />(s), <br />Model. <br />OKI SUMP Ser=r (3): <br />Model: <br />Leak Detector. <br />Model, <br />il [3Mechanical Line Leak DeteDtol <br />Model: <br />A Detector <br />Model: C <br />[]Electronic Line Leak Detector <br />Model: <br />g 'heensor: <br />-levl S <br />Model: <br />Munk Overfill/Righ-level Sensor! <br />Model: <br />r,.uip. t1ple and model in Section B on Page 2 <br />llQymu, <br />Di%penser ID! <br />0171 C ntainrnmt Scnsor(s): <br />Model: <br />D's enser <br />0 <br />ense Con�inmqnt Sensors: Model: 7]EEEE], <br />Fshveu <br />ZDispcAscr Containment Sonsol Model: <br />i Valve(s). <br />valve(s)J 1 <br />I ffghcar <br />Flo <br />QDi ensef Co� AN and chain(s) <br />Ml)ispeAse�T Containment Floaqs) and ChaiR(-q. <br />Dispenser TD, <br />q <br />rlDispenser Containment Sonsorl Model: <br />11111IRNT4,TkIll <br />0 Shear Valvc(s) <br />ODispenser Containment Float(s) and Chain(s) <br />*If the facility =#&in$ mort: tatl or dispensers, copy this form Include information for every tank and d4enser at this facility. <br />C. Certifleadf III - I certify that the equipment Idented to this document was Inspected/still In accordance with the manufacturers' <br />iluldallootmL A acbed to this Certification is information (og. manufacturers, cheddisn) necessary to verify th2t this information Is <br />rct land [t Plan showing the layout of monitonag equi t. For any equipment capable of generating such reports, I havc also <br />corea a " <br />' <br />attached a co , of the report; (chec* aU jl apply)-, <br />Mtem set-up UI�Carrn hiatll;� report <br />Technicianf g Block <br />signabire: <br />cel-tirication 0.: '? S <br />License No.: 598TOB <br />Testing Col Narne- TAIT ENVIRONMENTAL SYSTEMS Phone No.: (9 16) 858-1090 <br />Page I of 3 <br />03101 <br />Monitoring Systern Certification <br />