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MONITORING SYSTEM CERTIFICAT ON For Use By All.lurisdictions Within the State ofCalifornia23, servicingmonmeat. A S.�D.�rete certification e* report must be Authority Cited: Chapter 6.7, Health and Sajely Code; Chapter 16, Division 3, Title 23. California Code of or r Regulations Of this form must be provided This form must be used to document testing and the technician who perforins the work. A copy regulating UST systems ores M for each momtonag system control panel by of�fora to the local agency gu g 'stem ownerloperator. The owner/operator must submit a copy to the tank system within 30 days of test date- A. General Information_ Service Station No.: Facility Name: ` Zip: Site Address: 7d7 yvSrM,T �r 1�C1//Tr `i city: Contact Phone No.: Facility Contact Person: Date of Testing/Service: 4A__ V MakdModel of Monitoring System B. Inventory of Equipment Tested/Certified eceaerviced: Cheek hritbol to indicate ific ad meain e T ID: Tank D: Tank Gauging Probe: Model' ank Gauging Probe: Model. - Space or Vault Sensor Model: gra �ng Space or Vault Sensor: Mattel: .+ _ pmg Suatp,Trench Sensor(s): Model: � 7Yt 2v ipmg sump/Trench Sensor(s): Model: ❑F'll Sump Sensor(s): Model: OFiI Sump Sensor(s): Model: - Model: echanical Line Leak Detector. Model: echantcal Line Leak Detector. ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: level Sensor: Model: ❑Tank overfilUHigh-level Sensor: Model: ❑Tank Overfill/fligh- p. and model in Section E on Pa 2 []Other,S and model in Section E on Pa e 2 ❑Other.Specify Tank ID: Tank ID: 5 42 ❑ln-Tank Gauging Probe: Model: (�i-Tank Gauging Probe: Model: �nnular Space or Vault Sensor: Model: ' ' t+ 2C ❑Annng Space re Vault Sensor Model: Mudel: "V--Ld ❑piping Sump/Prench Sensor(s): Model: pp,ping SumplTiench Sensor(s): Model: OFill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): OMeehanical Line Leak Detector. Model: 2Mfechanical Line Leak Detector. Model: []Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank OverfilUAigh-levelSensor: Model: ❑Tank Overfill/fligh-level Sensor: Model: ❑Other S ni and model in Section E on Pa e 2 ❑Other S ui and model in Section E on Pa e 2 Dispenser Dispenser ID: 7''- e.t ❑Dispenser Containment Sensors: Madel: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ODi r Containment Flost(s and Chain s ❑Di nser Containment Flaat(s and Chain s) Dispenser ID •t; Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Madel: _ ❑ Shear Valve(s)- ❑ Shear Valve(s). ODispenser Containment Float(s)and Chains ❑Di Containment Floats and Chain s Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Madel: []Dispenser��Stainnent Sensor(s): Model: ❑ Shear Valve(s). CIDispensex Containment Float(s)and Chain(s) FiDispenser 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. Cer'tifleation - I certify that the equipment identified in this document was inspectedlserviced 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 Pian showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a coT of there ort; (check all that apply): ❑ System set-up LJ AJ hi ort Technician Name(Print): 9� r )Is Signature: --•'�(t Service Technician No.: by Z Certification No.: r L`( License No.: Testing Company Name: Champion Precision Testing Inc Phone No.: (661)363-7400 03,01 Paee I of 3 -