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MONI7. ORVNG SYSTEM CER'T'IFICATION For Use.Bv.=111,1urisdicnons ffithin the.State of California tuthorih°Cited Chapter 6.%, Hecilthacrd Safety-Code: Chapter 16. Division 3, "We 23, Caiilbrnia Code of Regulations Tlus form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be preparcd for each monitoring system controi oane' by the technician who performs the work. A copy of this form must be provided to the tank- system owner/operator. The ownerloperator must submit a cope of this fern to the local agency- regulating UST systems within 30 days of test date. A. General Informa 'on Facility Name: 1-0121 j J y Service Station No. Site Address: 1 L fl, /n L A/ City: b c Zip: Facility Contact Person: go 4 jj, Contact Phone No.: Make/Model of Monitoring System: Date of Testing/Sen'ic^• B. Inventory of Equipment 'Tested/Certified —`�t— Check thea ro cute boxes to:indicate ecific egu�menrt ins serviced: T ID: c a T ID: L,(v . (Z-4S- ank Gauging Probe: Model: Y 7 C'' Tank Gauging Probe: Model: �ular Space or Vault Sensor: Model: t� 3`C 4 z, Annular Space or Vault Sensor Model: T 5o Yt e ONping Sump/Trench Sensor(s): Model L,z i Y7 c.' SQ ping Sump/Trench Sensor(s): Model: r l4; ❑F" 1 Sump Sensor(s): Model: ❑F' Sump Sensor(s): Model: hanical Law Leak Detector. Model: eJ hanical Line Leak Detector. Model: K�- - O&C&C ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank OverfilUHigh-level Sensor: Model: ❑Tank Overfill/Efigh-level Sensor. Model: ❑Other_ SVEifv and model in Section E on Page 2 ❑Other. S ecify and model in Section E on Page 2 Tank ID: Tank ID: 1,4 a,+2.�1 i_ ❑In-Tank Gauging Probe: Model: ❑ln-Tank Gauging Probe: Model: ❑Atmular Space or Vault Sensor: Model: []Annular Space or Vault Sensor Model-. 7 S G -4'2e EW�iptng Sump/Trench Sensor(s): Model: 6,�5`f S c Z.6� ❑Piping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Madel: ❑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 Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Nlodel- ❑Other. S cifi and model m Section E on Page 2 ❑Other. S . type and model in Section E on Pae 2 Di r ID: Dispenser ID: S ispenser Containment Sensors: pDispenser Cona'gtainment Sensor(s): Model: hear Va1ve(s). ❑ Shear Valve(s). []Dispenser Containment Float(s)and Chain(s) ❑D r Containment Float(s)and Chain(s) Dispenser ID: Y Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). L❑Dispenser Containment Float(s)and Cham(s) __ DDiTenser Containment rloat(s)and Chains} Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: QDispenser Containment Sensor(s): Model: ❑ Shear Valve(s)- ❑ Shear Valve(s). Dispenser Containment Float(s)and Chain(s) ❑Dispenser Containment Float(s)and Chain(s) =If the faciiity 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 te.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipp L For any equipmmee t capable of generating such reports, l have also attach cd a copy of the report: (check all th,4 apply). Svs[em set-up :..7 Alarm history report Technician Name(Print): Ed Stearns _ Siaaatvrc: Certification No-: : I — 11 il) License No-: m — — Testing Company dame: Champion Prevision Testing _ Phone No.: (916) 927,-15 n;m,