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08/24/2004 09: 51 9169274 CHAMPION PT IN6 PAGE 03 (MONITORING SYSTEM.[ CERTIFICATION FOr ja luthc�r tv 0ted• LJiapter 6..7, lfe4dth nd Safety Code BVAJI t map iopts lPlt]b', DCvrs�n 3 Title 3,, Calijarnin Cade n�.gegularionr This corm must be used to dacuntent testing and servicing of monttaring equipment A Bred for Tach monitorirt>n system cautraE nine! by the technician who ---- ..� T7 he lank s td� .-� Mien or ,Ono b� System Owner/gpetator. The owner/ or a nock. A cop} of this Form mast ba provided Within 30 days of test date. Operator must subaut a coP,v of tbis forst to the local agency regulating UST systema A. General (Oformstion Facility Name: GJ97z�ear G`n r,-- ooj ✓b�C r• c Service Station No.; Site Address: /r�',e� q,�. �r,•c � City: YSE- � Zip: Facrluy Coxtiact Person: r9 ZlSJ F}t K p 3 2T Coruact - -- Phtme No.: MakeJModef ofMoniLoring System; j LS 35"c9 Date ofTesrioc Seng < B. Inventory of Equipment Tested/Certified Cheek the • risk byes to indicate siiic a >rervice T n C d: Task ID: c C Tank Caugtng Probe: Model: g'Lt t y l o �tmnlar Space or Vault Sensor. Model: i>tl?' F -�(O� ar Space r Vawe: Model l 5S �7 ('ung S"frreuch Sensor(s): Model: (97 7 £ }- b, pace or Vault Sensor Model: -e<Ft( '0_q dC , �Sump Sensor(s): Model / ng SloopTtetich Sensor(s): Medd: 2 3Fa•.Z6 hardoa1 Line Leak ❑Fill Sump Sensor(s): Model: Detecmr. Model: //6 G S 6 21(denhtmical line Leah Detector. Claemonic Line Leak Detector Madel: Model: OTank Overfi Mgb-levcI Sensor: Model: ❑Elects Attic Line Irak Detector Model; ❑Other, Sand overfilMSh-leve.!Sensor: Model: and mode3 in Satitm E on ❑Other, S and model in,Secdon.E on Pa 2 T ID: � r rc c- 2 " �a�' Tank ID: L1xn-Tank Ganging ftbe: Model: On-Tank roar Space or Vault Sensor; Model: 7`i 4 7Yo -47 �S Probe: 'Model• ❑Annular Space or Vault Sensor g SttmpPf tctich Sensor(s)' Modei: U>I e•�?0 7c k' ❑pi Model: Or Sump Sensor(s): Model: PsS p Scrisreach Sensor(s): Model: echanticzi Linc Leak DcL-cfor. Model. GFill Saatp Sensor (s): Model: C]ElcclPoitic Line Leak Detector Madel: 1(6 `l� ❑Mechanic!Use Leak Detector. lvro(ld: ❑TankOverfli/ igh-IcveiSensor: Model: OElcctnoaicLint LeakDetector Model: 00ther, S e ' and model in Section Eon P 2 F- rank /ITtgis-level Sensor: Model: Dispenser ID" ❑Outer. S anis model in 5ecn an E on 2 I ,T qer Containment Sensors: Model: Dispenser ID: a hear Vaive(s). c OBfi""eer Containment Sensar(s): Made}: onii Containment Fl s and Ch ' s E rfiar Valve(s). D er ID: f e6 Ctmlammem Float(s)and Chain s Di wer i�er CSpenser ontsinmem.Setssors: Model, ©"Shear Vahe(s). L9 spicnser Crmtaiameat Sensor(sy Model: 2_0 Containment FMIoat(s)and Chan s C'J-56ear Valve(s). DtWser ID• OD" Coamincmcm•FlPaUs and Chain s} ClUiapenser Containment Sensors: Model Dieser Ip: 0 SIu=Valve(s), ElDispenser Caataintneat Scasor(s): Madel: ODi eraser Containment Floats and Chaiu(s) LI Sheat Valve(s). �If the Facility cotnam' more tanks or di ❑Di Containment Floats)and Chain S �.�Py this form- Include information for eery tank and dispenser at this tauzlity. C. Certification - I certify that the a ui se maaofactare•,s' u 4 ptaent identified in this dacnment was rns "iced in aemniance with the aldeilnei. Attached ro this CeRinearion is inibrnta6on (e.g.mannfarnurers' cNe�Itfists)necewgary to verify h t information Is correct and a PLn Plan showlitg the Isyngk of monitoring eggipmyi{k For any equipme apabie of genernttng with uch reprlR9,f have also attached a curly of the ropnrt: (+*+ *a!(ihar �' is Trhnician Name(print): Ed Stearns �Dh') Syshm set-rap AI hi ry re arc CertiticrtionNo.: S zrl— Signature: Testing Company Vane: . Cltninuion P ecivanT License No.: