Laserfiche WebLink
E <br />Appendix V1 <br />(copies of monitoring System oefflioa#won trm and UST Nbreoring Plot Plan avaflWe M <br />MONITORING SYSTEM CERTIFICATION <br />For Use By AN JurixWOns 111010 V* SWe of Q00mia <br />Auftrily Cited.- ChWer a 7, fkalth and Softly Code; Chapor 1$, Dh4sion 3, Title 23, California Code of <br />Regulations <br />This form must be used to document testing and servicing of manlwng equipment A separate cert ffication or report must t* prepwed for <br />each monitoring system control panel by the technician who Worms the work A copy of this torm must be provided to the tank system <br />owned or. The owner must submit a copy of this form to the local aMey regulaft UST systems wither 30 days of lost date. <br />A. 00wal Ifftnualibn <br />FacRy Name. Tulare Famis, LLLC. Bldg, No.. <br />So Address: 2771 E FrenCh Cast p Rd City. Manteca - ap:95336 <br />Facay Contact Pawn: Michael ENar conlacl, Phone No.: (2gg_j 235-3055 <br />Model of Mon jwM System VR TL5-350 PLUS - Dale of ToWng/Servicing: 6 15 12 0 j 4 <br />a CortificaUan - I cwft GM the equlpnwd kUnUffed in this document was inspedefterV100d In 2000141afm WO the MUnublCONOIC <br />fisiddlo,046 Auw*Ad to this Card0cotton to k0onrofflon (e.g. mentdootuverer c necessary to veft ttwt this IntOUSUM Is correct <br />and a Plat Plan muWng efts layout of awnlioring equipment For any eQuIpment cepaWs of generating sucti reports, I have also attwhod a <br />copy of the report; (W-mk 90 Met 4pply): - SVSKVR SOUP L Alone tistory report <br />Technician Nome WMQ: Carl Waype_Hendemon SOWAUM: <br />CwWrAffion No.: 5252923 ICC License. No.: A25001 GVR <br />-Tesung Company name: HMC -Henderson Maint Co — Phone No.1 209 ) 467-7573 <br />Te" C40WV Address: PO Box 31325 - Stockton, CA 95213 _ Date of TwUnWsavlov: 6 5 1, 2 0 1 4 <br />moraoft *S*m coroft"on Palp t of 4 <br />12107 <br />REGEjVED <br />3U� 10 ZW4 V21/07 <br />R0NMENTA1- <br />