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MON14 ORPNG SYSTEM CERTIF1CAT 1C�� D For I,,-se BvAll.iurisdictions Ifithin the State o(C alifi)rma .-luthority Cited., Chapter 6.7, Heuith and Safen)Code: Chapter 16. Division 3, T.;tle ' , Calil'o c TKA 94 &�kations This form must be used to document testinu and servicing of monitoring equipment. A se 4. '7 must be preaared for each monitoring, system control cane' by the teciutician who performs the work. A :.op`, eProvided to the tank system owner/operator. The owner/operator must submit a cope of this form to the local agency ti T Am within 30 days of test date. A. General Informa 'on _ Facility Name: LO p j ( 2 y L, Sen ice Station No. Site Address: t '�3 t -- - +-{ - In ,� City: �b!�t _ Zig: Facility Contact Person: /�'e C't ry: Contact Phone No.: Make/Model of Monitoring System: 5_0 Date of Testing/Servi— 122- B. 22- B. Inventory of Equipment Tested/Certified Check the ippEMAate boxes to indicate Tecific a men t ins serviced: T ID: to T ID: i �L• �4 S a ank Gauging Probe: Model: Y "YCr � i Tank Gauging Probe: Model: alar Space or Vault Sensor. Model.- & t t 7 tc.- z0' Annular Space or Vault Sensor Model: c:,7 750-Y2 c ping Sump/Trench Sensor(s): Model: �7 i Y7�� 1 ' '� �iping Sump/Trench Sensor(s): Model: 1,0 �--Z��-; ❑Fill Sump Sensor(s): Model ❑Fill Sump Sensor(s): Model: echanical Line Leak Detector. Model: 5 7-f^PI&�O--t) Mechanical Line Leak Detector. Model: Z C% ❑Electronic Line Leak Detector Model: ❑Ele;Ironic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/Itigh-level Sensor. Model: ❑Other- S and model in Section E on P c 2 ❑Other. SeEa am and model in Section E on Paue 2 Tank ID: Tank ID: t1 i.t y9 L ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model. ❑A.put lar Space or Vault Sensor: Model: ❑Annuiar Space or Vault Sensor Model: Eiping Sump/Trench Sensor(s): Model: 6,i}Y �,z ) ❑Piping Sump/Trench Sensor(s): Model: % 7 ' 3 C•Z a ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: []Electronic Line Leak Detector Model: ❑Electronic Line leak Detector Model: ❑Tank Overfillf igh-level Sensor. Model: ❑Tank Overfill/High-level Sensor. Model: ❑other- S cifv and model in Section E on Paee 2 ❑Other, S . type and model in Section E on Page 2 Dispaser ID: - Dispenser ID. RIDispenser Containment Sensors: Model: 02'"12f'a-20,5- ❑Dispenser Containment Sensor(s): Model: hear Valve(s). ❑ Shear Vaive(s). ❑Dis user Containment Float(s)and Cham(s) ❑D' r Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ er Containment Float(s)and Chain(s) _ PI)tsanser Containment Float(s) and Chain(s) Dispenser ID: Dispenser ID- ❑Dispenser Containment Sensors: Model: pDispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Di enscr Containment Float(s)and Chain(s) []Dispenser Containment Float(s)and Cham(s) "If the facility contains more tanks or dispensers, copy this form Include information for even tank and dispenser at this facility. C. Certification - 1 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 equip L For any equipme t capable of venerating such reports, l have also attached a copy of the report: (cheek all thra appl}'): System set-up alarm piston report Tecitmman Name(Print): Ed Stearns Signature: Certification No.: / I L j License No-: — Testing Company Name: Champion Precision Testing --- Phone No._ (91Ei) 92 i Z-7 - r:zmi