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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control Panel by the technician who performs the work A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: U_ ill1 e y Al C G Service Station No.: Site Address: j 1 Aly i4l,4 i Ci , ty: �.0 K /o ,I Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System:li %' ,J e v v j 7- rL S' - ?f Z Date of Testing/Service: ly - j"- 06- B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equiomen� T ID:( Y Tank Gauging Probe: Model:tim alar Space or Vault Sensor: Model.- (j)FifY jaij0 - e iping Sump/Trench Sensor (s): Model: o!Y 4,1?r, ❑Fill Sump Sensor (s): Model: ❑Mechanical Line Leak Detector. Model: 1!16ectromc Line Leak Detector Model: /1_ ❑Tank Overfill/I-ligh-level Sensor. Model: ❑Other, Specify equip. type and model in Section E on Page 2 Tan ID: y j ❑ Shear Valve(s). auk Gauging Probe: Model: !J1 MGnular Space or Vault Sensor: Model: (0)--ygL?w -/{- iping Sump/Trench Sensor (s): Model:?alt! ��Ct Zc ❑Fill Sump Sensor (s): Model: ❑MeChanical Line Leak Detector. Model: Iectronic Line Leak Detector Model: ❑Tank OverfilMgh-level Sensor. Model: ❑Other, Specify equip. type and model in Section E on Page 2 Dispenser ID: 1 <- 2. Tank ID: K -11 WtTank Gauging Probe: Model:�- d roar Space or Vault Sensor Model: 74- V 7��, Sump/Trench Sensor (s): Model: 0 e'`�'t!`` `,7 ❑Fill Sump Sensor (s): Model: ❑Mechanical Line Leak Detector. Model: Lfectronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor. Model: ❑Other: S and model in Section Eon Pa e Tank ID: ❑In -Tank Gauging Probe: Model: ❑Annular Space or Vault Sensor Model: ❑Piping Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/ETigh-level Sensor Model: ❑Other, Specify equip. tvoe and model in Section E on Page 2 Dispenser ID: 7.4y Y 12Piping ❑Dispenser Containment Sensor(s): Model: 2 OR - 0 Shear Valve(s). ❑ Shear Valve(s). 013ispenser Containment Floats) and Chain(s) DDispenser Containment Float s) and Chain(s) Dispenser ID: S -a-6 Dispenser ID: ❑Dispenser Containment Sensors: Model: Dispenser ID: 1 <- 2. Dispenser ID: 7.4y ❑Dispenser Containment Sensors: Model: S' ❑Dispenser Containment Sensor(s): Model: 2 OR - 0 Shear Valve(s). ❑ Shear Valve(s). 013ispenser Containment Floats) and Chain(s) DDispenser Containment Float s) and Chain(s) Dispenser ID: S -a-6 Dispenser ID: ❑Dispenser Containment Sensors: Model: ti ❑Dispenser Containment Sensor(s): Model: 2p X ❑ Shear Valve(s). ❑ Shear Valve(s). QDjyenser Containment Float(s) and Chain(s) ❑D" user Containment Float(s and Chain(s) Dispenser ID: '}-1 U Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s) []Dispenser Containment Float(s) and Chain(s) *If the facility contains more tanks or dispensers. copy this form. Include information for every tank and dispenser at this facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e:g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Ptah showing the layout of monitoring equippment. For any equipm capable of generating such reports, I have also attached a copy of the report;.c neck all that apply): Mystem set-up FA history report Technician Name (Print): �ej / C' G: Signature: - Certification No.: /)a Y}' License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (916) 927-1557 page. 1 of 3 of/!;t