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WLSI�Emu v Iry �. JAN 14 2008 I ENT HEALTH MONITORING SYSTEM CERTIFICATWSERVICES 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 ofRegulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must t prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provide to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systen within 30 days of test date. A. General Information Facility Name: Qa_ K KLE�nJ Service Station No.: ^— Site Address: -7o-7 t- t YoS�.�t�7` AU-44- City: -4f T`�G4 Zip: e1 C33(o Facility Contact Person: Fflht e*-�to Contact Phone No.: tY- (.Z-7%( Make/Model of Monitoring System: V ec 3 t>u� Date of Testing/Service: i t/S/o-t B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment in ed/serviced: Tank ID: / - S7 Tank ID: 3 - t71*'16z4 Tank Gauging Probe: Model: -o Tank Gauging Probe: Model: w.6�_a IFT;Gnular Space or Vault Sensor: Model: 74y7 L76-Yo7 CtaCrinular Space or Vault Sensor Model: W5e7,?o-yo C36'ping Sump/Trench Sensor(s): Model: - [ ping Sump/Trench Sensor(s): Model: za [Hili Sump Sensor(s): Model: OfITI Sump Sensor(s): Model: 20;chanical Line Leak Detector. Model: RiMe-chanical Line Leak Detector. Model: 4're-M i-➢- ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Ovenll/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑other, Specify equip. and model in Section E on Pae 2 ❑Other, Specify equip. type and model in Section E on Page 2 Tank ID: .2 -9'l Tank ID: Tank Gauging Probe: Model: -o ❑In-Tank Gauging Probe: Model: pX�nnular Space or Vault Sensor: Iblodel: -7-778o—v0 ❑Annular Space or Vault Sensor Model: [ping Sumpll'rench Sensor(s): Model:/7q 3 a —aey ❑Piping Sump/Trench Sensor(s): Model: [31`ill Sump Sensor(s): Modell ❑Fill Sump Sensor(s): Model: 311eechanical Line Leak Detector. Model: p ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: []Tank Overfill/High-level Sensor: Model: ❑Other,Specify ui and model in Section E on Pae 2 ❑Other, Specify equi . type and model in Section E on Pae 2 Dispenser ID: f -Z Dispenser ID: 7 -V M15tspenser Containment Sensors: Model: 004spenser Containment Sensor(s)i Model7p�zgo-za` [31hear Valve(s). 2-Shear Valve(s). 013ispenser Containment Floats and Chain(s) ODispenscr Containment Float(s)and Chain(s) Dispenser ID: '3 -Ir Dispenser ID: BHispenser Containment Sensors: Model74vzgo-7m ❑Dispenser Containment Sensor(s): Model: ErShear Valve(s). ❑ Shear Valve(s). ❑Dia enser Containment Floats and Chain(s) DDispenser Containment Floats and Chain(s) Dispenser ID: Dispenser ID: pDispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: EfShear Valve(s). ❑ Shear Valve(s). DDispenser Containment Float(s)and Chain(s) ODispenser Containment Floats 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 - t certiry 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 h correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, t have also attached a copy of the report; (check allthat apply): aystem set-up �ytd Alatin hi ry Technician.Name(Print)* 49t , u i , �t""iJ Signature: d1XL_ Service Technician No.: OSS71?c/4 --cT Certification No.: /I %7't /-S License No.: $yg t$-a Testing Company Name: Champion Precision Testing, Inc Phone No.: (661)363-7400