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MONITIORLNG SYSTEM CERTIFICATION For L%se 13v .111 Jurisdictions Within the State of California Authority Cited: Chapter 0. 7, Health and Safety Cude: Chapter 16, Division 3, Title 23, California Code of Regulations Tlus form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control wel by the technician who performs the work. .4 copy of this form must be provided to the tank system owner/operator. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Info ation Facility Name:S',r' r-` Service Station No.: Site Address: � City: 7c:;e ,,- Zip: Facility Contact Person: Make/Model of Monitoring System: Contact Phone No.: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Date of Testing/Service: ; - "? -- = 'r Tank ID:c.: Tank ID: 7 Ze,71<_ ffn-Tank Gauging Probe: Model:, j'�,u'G / [fin -Tank Gauging Probe: Model: pAnnular Space or Vault Sensor: Model: [Anular Space or Vault Sensor Model: 21iping Sump/Trench Sensor (s): Model: j r pPiping Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: []Iviechanical Line Leak Detector. Model: 1�7j [2Mechanical Line Leak Detector. 'Model: ❑Electronic Line Leak Detector Model: [--]Electronic Line Leak Detector Model: ❑Tank Overfi][Mgh-level Sensor. Model: ❑Tank OverfilUHigh-levet Sensor. Model: ❑Other. Snify e in and model in Section E on Pae 2 ❑Other. S ui and model in Section E on Pae 2 Tank ID: Tank ID: pin -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: 2Ammlar Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor Model: Onping Sump/Trench Sensor (s): Model: 79,/ .. � , C '- ❑Piping Sump/Trench Sensor (s): Model: ❑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 Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other. S2Efy ,., ui _ DE and model in Section E on Pae 2 ❑Other. S cifvw and model in Section E on Pa e 2 Dispenser ID: Dispenser ID: 211ispenser Containment Sensors: Model: 7i 5e3,e,-c DDispenser Containment Sensor(s): Model: 'J;' _ ; ,��• tp'Shear Valve(s). 2 -Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s) ElDispenser Containment Float(s) and Chain(s) Dispenser ID: -- Dispenser ID: dispenser Containment Sensors: Model: e) ❑Dispenser Containment Sensor(s): Model: 17 Shear Valve(s). ❑ Shear Valve(s). DDispenser Containment Float(s) and Cham(s) ❑D user Containment Float(s) and Chain(s) Dispenser m: ,j - (::;� Dispenser ID: 00ispenser Containment Sensors: Model: Z� ,,F` ❑Dispenser Containment Sensor(s): Model: C3 -Shear Valve(s). ❑ Shear Valve(s). ❑Di r Containment Float(s) and Chain(s) ❑Dia nser Containment Float(s) and Chains) j *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at this facility. C. Certification - t 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 Plan sho,%ring the layout of monitoring equipment. For any equipment capable of .generating such reports, t have also attached a copy of the report. (check du that apply): system setup a"Alarm history .report Technician Name (Print):/.,`57`r',-, Signature:.�— Certiiication No.: ✓UG _ �- 5 _—G License No.: Testing Company Name: Champion recision Testing, Lac Phone No.: (916) 92? -1»7 Pstae. t of i 3-4iol