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MOIOPJNG SYSTEM CE CA TI®N <br /> FbrVSC ByAlllur&Z ictjO=Ur hia theS:oteofCagomLa <br /> Acahortty Cited-CI-pter6.7.11ealth aadSafwy Cod-_-ChvprwJ6.Di*wn3,Title 23,California Code afRegulalioas <br /> This form mast be reset to dotxrmcat testingaad txtvrtciqgof mojkwdngogA 0oatatc ect6fication or aoort must be <br /> for tach monitoring system'Cotrtroi vancl by tfto tedwiciaa who performs the work. A Copy of bus form must be provided to the tang <br /> owncdop=w_ Ike owwdoperjtw mast saber&a'COPY of this form to the 10ed agency reguia UST SYSICCIM within 30 <br /> days of tat dad-, <br /> A.. General info 'on <br /> FacilityNamer - Bldg.No -- <br /> Site Address: J. Cty 1 ?- -- <br /> Facrlity Contac Pen n: Contact Phone No:(V OT 1,�"7T7"C, _ <br /> MakdlModd of Modtorwg System: Date of Testinp�Servicing: <br /> B. ]inventoryof ' mentTeste&Cetd Taaf <br /> Tank ID: k1D- <br /> 3 In-Tank Gwgrrtg Probe Mudd: A In-TankGangatg Probe. Mudd <br /> XAtmtdwSp=(w'V=kSeasot: Model- Arm brSpaoearVat&Scam Model: <br /> P4*gSUwITrtraehS=sw(s). Moeid: PipMSamplT='&Seasoc(s). Mod& <br /> ❑EXSuW Seasa(s). Mod&: ®Ew SwP ]L Model: <br /> Mo IUneLakDetoaat: Mode�1:.�Lf ModutniadUwL*Daoaor. Model: <br /> ®Etoc6w=L=eLakDaoaot: Mold: EIocamicUneLakDe=we Model: <br /> TankOenx6ltlFrr&4,c dSensac Mold; Sal C�-� Tx*Ovuflt/H- .Seas 140d&-_ �� <br /> ®Odwj and model in Seca=Eon 2. ®Other( and mod&in Soaiw Eon 2. <br /> TankID; TankID: <br /> IN In-TankGaggittgPmbG" Model: ®IU-TaakGaU&gProbe. Moder <br /> < AnnularspaeeorVwkSensoG Model:. ®AnnularSpweorVaaltSatsoc: Model: <br /> Piping Sump/Trench Sensoc(s). Model: ® Piping Sump/Ttrnedt Sensot(s). Model: <br /> ® FII Sump Scusor(4 Model: 0 H Sump Seasor(s). M <br /> odet <br /> Medrazricd line L-ak Detector. Mudd: LA4LO> ®Modranical Line Lak Ddxnw. Model: <br /> Ekw onic Line Lcak Daoaor. Model:® ®Electronic LincLak Dao-(or. ModcL- <br /> Tank Overfill I I igh4,ev l Sensor. Model:_ d� ®Tank Overfill II gig-evel Sensor. Model: <br /> a other(s ui t and model in Section E on Pa c 2). ®.Otho( tri t and mold in Scaion—Eon P c2)- <br /> Dispenser ID: Dispenser ID: <br /> 0 Dispcasa Containment Sensoc(s)- Model: ®DispatserOortminment Se dsor(s). Model - <br /> Shear Valvc(s). ®Shear Valve(s)- <br /> D Containment Floats)and ChaWs). ®Di Containment Roat(s)and Chain(s). <br /> Dispenser ID: 'Dispenser ID- <br /> ® Dupers r Containment Sensm(s). Model: ® D' Containment <br /> ssparsa Sauoc(s)_ Mudd: <br /> Shear Valv,*). ®Shear Valvc{)_ <br /> Dispenser Containment Floa(s)and Chain(s). ® Containment Float(s)and Chaia(s). <br /> Dispenser ID: Dispenser ID: <br /> ®.D"tspcnsaContaituncntScnsot{s). Model: O DisperucrCoatainnaattScrosot(s). Mod& <br /> a Shear Valvc(s). ® Shear Valve(s). <br /> ® Containment FloA(s)and Chaim(s). a Dispenser Containment Float(s)and Chain(s). <br /> •If the facility contains more tanks or dispcasas,copy this form. Include information for every tank and dispenser at the facility. <br /> C. CCIlif,C260n-1 certify that the equipment identified in this document was inspected/setvioed in accordance with the manufacturers, <br /> guidelines. Attached to this Certification is information (e-g. manufacturers'cheddists)necessary to verify that this information is <br /> Correct and a Plod Plan showing the layout of monitoring equipment- For any Tp—t capable of generating such reports I have also <br /> attached a Copy of the r rt;{the all p[yJ: System set-up/ history report <br /> Technician Nance(print): rK Signature: <br /> Certification No,: �� License_No.: CK�IGL <br /> Testing Company Name:Tt ,nV F CW ct 2OM0_n ` Phone No js VED_) SaQ -7 p aQ <br /> J <br /> Site Address: `� �� k t� d���cnk cn qtS Date of Tesang/Servicing: <br /> \lunit<,tin �.a�tu�rrtifii-tliun <br />