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U ut=,u `--�U l'i L - MOVITORING SYSTEM CERItICATIM i 4 Zoos k�q For Use By All Jurisdictions Within the State ofCalifornikNVI 0 AIEN Authority Cited- Chapter 6.7, Flealth and Safety Code; Chapter 16, Division 3, Title 23, C fT v ations This form must be used to document testing and servicing of monitoring equipment. A e certi da h Pt'reoort 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: A) Service Station No.: -- Site Address: -70-7 tt if V4- City: Zip: Facility Contact Person: Contact Phone No.: -2.4, ?-StY- 6� 7Y Make/Modet of Monitoring System: y ec 3 tm Date of Testing/Service: i e/S/o"r B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ed/serviced: Tank ID: / - S7 Tank m: 3 [�n-Tank Gauging Probe: Model: -o lin-Tank Gauging Probe: Model: C rtnular Space or Vault Sensor: Model: 174y3 9a-Yo BWm- ular Space or Vault Sensor Model: W 7yd-107 ElAping Sump/Trench Sensor(s): Model - pl iping Sump/Trench Sensor(s): Model: a-xa 1211111 Sump Sensor(s): Model mill Sump Sensor(s): Model: Ql�echanical Line Leak Detector. Model: 4'T0-.a c D RMe-chanical Line Leak Detector. Model: -m t-➢-D []Electronic Line leak Detector Model: ❑Electronic Line Leak Detector Model ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, Specify u' and model in Section E on Pae 2 ❑Other, Spacify equip. t3rpe and model in Section E on Pae 2 Tank ID: 2 -9'i Tank ID: MTn`Tank Gauging Probe: Model: � <4-Cr--o ❑In-Tank Gauging Probe: Model: R<nnular Space or Vault Sensor: Model' ❑Annular Space or Vault Sensor Model: [.}i�tping Sump/Trench Sensor(s): Model:/7q -51-a —20 ❑Piping Sump/Trench Sensor(s): Model: Brill Sump Sensor(s): Model:l ❑Fill Sump Sensor(s): Model: 31&hanical Line Leak Detector. Model: -5P.a e-D ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: []Electronic Line Leak Detector Model: ❑Tank Ovcrfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, Specify ui . type and model in Section E on Pae 2 ❑Other, Specify eguip. type and model in Section E on Pae 2 Dispenser ID: /_Z_ Dispenser ID: 7 -g Erl5ispenser Containment Sensors: Model:-71ry->go-v-og DDispenser Containment Sensor(s): Model-7? s$O^meq ETSrhear Valve(s). 05hear Valve(s). ODispenser Containment Floats and Chains DDispenser Containment Floats and Chain(s) Dispenser ID: - Dispenser ID: 9f)ispenser Containment Sensors: Model:7Tvsjo-Zm ❑Dispenser Containment Sensor(s): Model: Er-Shear Valve(s). ❑ Shear Valve(s). ElDispenser Containment Floats and Chains ❑D' ser Containment Floats and Chain(s) Dispenser ID: s -6 Dispenser ID: Mispenser Containment Sensors: Model:--r?V $6-7a ❑Dispenser Containment Sensor(s): Model: dShear Valve(s). ❑ Shear Valve(s). ODispenser Containment Floats and Chains 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 - 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 copy of the report; (check all that apply): ®'System set-up f,2 Alarm hr ry Technician Name(Print): iqc ✓.,u 4, �f t[i!¢RtJ Signature: -__ Service Technician No.: 08?1Wc/,r -_,t,'7- Certification _,cTCertification No.: /1.%.7.1Y-5License No.: TVS/Sa Testing Company Name: Champion Precision Testing, Inc Phone No.: (661)363-7400 Paee I of 03/01