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SYSTEM CERTIFICA`!iON MONITO G S . For Use By All.furisdietions Within the State of California Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3,Titl le A 3 Porn a Code ort Regulations nirist � This form must be used to document testing and servicing of monitoring equip this forth muse be proms �h monitories System control iranel by the technician who performs this form to the local agency regulating UST systems to the tank system-owner/operator. The ownerloperator must submit a copy within 30 days of test date. A. General Information Service Station No.: Facility Name: ��-.� t' i rr� r{x � a L- �- / 7-7;j�' City Zip. Site Address: % Facility Contact Person: Contact Phone No.: Date of Testing/Service: c� Make/Model of Monitoring System: 1/ - /� , S �� - B. Inventory of Equipment Tested/Certified CIDispenser Containment Float(s) and Chain(s) Denser ID: " f ( tspenser Containment Sensors: Model: Check the nate bones to indic2te specific equipment ' serviced: Valve(s). Tank ID: 1 X 17 ODispenser Containment Floats and Cham(s) Tank ID: Z- 1 pan -Tank Gauging Probe: Model: Tank Gauging Probe: Model: zt--4 Model: ` �,.. ?,C ' Mode p'Annular Space or Vault Sensor �< Model: 6 . Space or Vault Sensor: p g SSumpTrench Sensor (s): Model: '_ °i z/ ? �;� . �� 012 i ping Sump/Trench Sensor (s): Model: �, Model: Sensor ( Model: — — ❑Fill Sump Sensor (s): 1 dMechanical Line Leak Detector. Model: OMeSump e Detector._ echanical Line Leak Model: _ <:a Model: eak Detector mac L�� Model: pEleetronic Line Leak Detector Model: [],Tank levelSensor: Madel: []Tank OverfilUHigh-level Sensor: model in Section E on Pae 2 ❑Other, Specify equip. typeand model in Section E on Pa e QOther, g and ID: - Tank Gauging Probe: F'Annular Model: ,r`'14. Y. -.1 Tank ID: ❑ln-Tank Gauging Probe: Model: Space or Vault Sensor: Model: ? ? ` �t 7< c ❑Annular Space or Vault Sensor Model: Ofqping Sump/Trench Sensor (s): Model: e -t r" - _1 c []Piping SumpfTrench Sensor (s): Model: []Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: [3fdochanical Line Leak Detector. Model: I � e f ❑Mechanical Line Leak Detector. Model: QElectronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: []Tank Overfi Mgh-level Sensor: Model: ❑Tank OverfilUHigh-level Sensor: Model: in Section E on Page �, g and model in Section E on Pa e 2 ❑Other, S ui and model nser ID: 1 � 2 Dispenser ID: 7 g �-f Vjspenser Containment Sensors: Model: '� QDispenser Containment Sensor(s): PfChnar ValvPfcl Model: 2—C, •3 [?f Shear Valve(s). ODispenser Containment Floats and Chains CIDispenser Containment Float(s) and Chain(s) Denser ID: " f ( tspenser Containment Sensors: Model: nser ID. �G r penser Containment Sensor(s): Model: a Fshear Vah*s). Valve(s). CdShear Opispenser Containment Float(s) and Chain(s) ODispenser Containment Floats and Cham(s) Dispenser ID: Dispenser ID: []Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: Q Shear Valve(s). ❑ Shear Valve(s). riDicriencer Containment Float(s) and Chain(s) ODispenscr 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. CertirCltlon - 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 torted and a Plot Plan showing the layout of monitoring equipmSxC/ For any equipm ;nt capable of generating such reports. I have also attached a co q of the ort; (check all that apply): System set-upd�� h or" Technician Name (Print): e r i t Signature: Service Technician No.: S d `ici Z Certification No.: S!•z �( License No Testing Company Name: Champion Precision Testing Inc Phone No.: (661) 363-7400 03/01 page I of 3