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MONITORING SYSTEM C ERTIFICAON For Use By All.lurisdietions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations ['his form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be nvnared for each monitoring system control Panel by the technician who performs the work. A copy of this form must be provided o the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems Nithin 30 days of test date. A. General information C' Service Station No.: Facility Name: , Site Address: / U !`C �t r ! l �c.' 4/c?. �/ City: (C Zip: Facility Contact Person: P�11 Ld, Contact Phone No. Mahe/Model of Monitoring System: i,, n 7"L S s' S v Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific egnipment ins weted1serviced: Tank ID:h=) T� ID: `�'t _. pia -Tank Ganging Probe: Model 4 ' _ Qin-Tank Gauging Probe: Model: <t t ' 'i c Gr cur Space or Vault Sensor Model: C Annular Space or Vault Sensor: Model: 4 -"{ ❑Piping Sump/Trench Sensor (s): Model: o 7,'i 2`0 - .AD`S ClPiping Sump/Trench Sensor (s): Model: 71, �` c' •2i . ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Mechanical Line Leak Detector, Model: ❑I 4echanical Line Leak Detector, Model: ©$lectronic Line Leak Detector Model: BElectronic Line Leak Detector Model: ❑Tank OverfilMgh-level Sensor: Model: ❑Tank OverfilMgh-level Sensor: Model: model in Section E on Pae 2 ❑Other, S and model in Section E on Pae 2 ❑Other, S and Tank ID: [11n -Tank Gauging Probe: Model: c; 1 Tank ID: ❑ln-Tank Gauging Probe: Model: I alar Space or Vault Sensor: Model: ? Et �, 4 L' �t �`�' aping ❑Annular Space or Vault Sensor Model: QR Sump/Trench Sensor (s): Model: �,q ❑ping Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: _ 0mcchanical Line Leak Detector- Madel: ❑Mechanical Line Leak Detector. Model: E�Electronic Line Leak Defector Model: Z( -I-( (,CD - ❑Electronic Line Leak Detector Model: ❑Tank Overffi"gh-level Sensor: Model: ❑Tank OverfilUHigh-level Sensor: Model: ❑Other, g and model in Section E on Page 2 ❑Other, S ui and model in Section E on Pa 2 Dispenser ID: 9 " Z []Dispenser Containment Sensors: Model: Dispenser ID: 7 :- I / ❑Dispenser Containment Sensor(s): ` Model: K." ❑ Shear Valve(s). ODispenser Containment Floats and Chains ❑ Shear Valve(s) oDispenser Containment Float(s) and Chain(s) Dispenser ID: 5 - Dispenser ID: ❑Dispenser Containment Sensors: Model ` ✓ ❑Dispenser Containment Sensors) Model ❑ Shear Valve(s). ❑ Shear Valve(s). ODispenser Containment Fl s) and Chain(s) QDispenser Containment Float(s) and Chain(s) Dispenser ID. ) Dispenser ID: ❑Dispenser Containment Sensors: Model: 2(-) 5 []Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). CIDispenser Containment Float(s) and Chain(s) DDispenscr 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 Plan showing the layout of monitoring equipment For any equipment capable of generating such reports, I have also attached a co of the re ort; (check all that apply): Cl System set-up h Ort Technician Name (Print): C_ ►— hS Signature: _ Service Technician No.: S U 1Y Z Certification No.: > 1 i License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (661) 363-7400 Psee 1 of 3 03101