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MONITt,AF G SYSTEM CERTIFIC_$TION AUG 1 7 2004 For Use By All.lurisdietions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Co`%VjA9*�W HEALTH This form must be used to document testing and servicing of monitoring equipment. A senarate certificatjo§u 'ls%e prepared for each monitoring system control panel by the technician who performs the work A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Service Station No.: Site Address: l�:� 5, L.iJ�i<y�dJ ST City: Zip: q . -31 Facility Contact Person: 7-1/11 /= i /L Contact Phone No-: `1 - '-L— o �. Make/Model of Monitoring System: ti�4E-D �z i s T Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check the ro riate loxes to indicates cific a uipment inspected/serviced:_ Tank ID: /' t t i� i. r'7Jt_ i� f i' - Tank ID: i j cs2_ 21n-Tank Gauging Probe: Model: — I1n-Tank Gauging Probe: Model: D16mular Space or Vault Sensor: Model: QArmular Space or Vault Sensor Model: ®piping Sump/Trench Sensor(s): Model: -1.. Eriping Sump/Trench Sensor(s): Model: -7j<,3 _fir,0 Ij ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: C Mechanical Line Leak Detector. Model: 6..Ti-i-zzr EMechanical Line Leak Detector. Model: e-P z.,_`c, ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: []Tank Overfill/High-level Sensor. Model: ❑Tank OverfillAEgh-level Sensor: Model: ❑Other. S cifvui . !pLc and model in Section E on Page 2 `' ❑Other" S cifc equip. IEFand model in Section E on Pae 2 T ID: ,_ /ZMru�1 J1 Tank ID: n-Tank Gauging Probe: Model: ,ftA ❑In-Tank Gauging Probe: Model: B%Crmular Space or Vault Sensor. Model: 7- ❑Annular Space or Vault Sensor Model: [Riping Sump/Trench Sensor(s): Model: `;7? - ❑Piping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: OMechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: R ❑Tank OverfilMgh-level Sensor: Model: []Tank OverfilMgh-level Sensor: Model: ❑Other. S cif` and model in Section E on Pae 2 ❑Other. S city and model in Section E on Pae 2 Dispenser ID: 1 ` Dispenser ID: []Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: CYShear Valve(s). Q' hear Valve(s). [ i nser Containment.Float(s)and Chain(s) _ _36is user Containment Float(s)and Chain(s) Dispenser ID: -3 - Y Dispenser ID: []Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ['Shear Valve(s). ❑ Shear Valve(s). 266 user Containment Float(s)and Chain(s) ElDispensa Containment Float(s)and Chain(s) Dispenser ID: 6-lc _ Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ("Shear Valve(s). ❑ Shear Valve(s). E#Di nser Containment Float(s)and Chains) ❑Dis nser Containment Float(s)and Chain(s) *If the facility contains more tanks or dispensers, copy this form. Include information for event tank and dispenser at this faciliny. 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 (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): C3-System set-up O'Alarm history report.. Technician Name(Print): 14,L v r lu L, Signature: Certification No.: ; u License No.: Testing Company Name: Champion Precision Testing,Inc Phone No.: (916)927-1557 PAVP t ��f:; n3im