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.NIONITORLNG SYSTEM C'ERTIFICA'TION For 6,w_Hv.h11 Jurisdicrtvne Ifithin the State ofCalifimnra i uthority Cite& Chapter 6.7, ffectlth and Safety('ode: t-hapter 16, Division-3, '."We 23, Cahlornui crude o/Regulations This form must be used to document testing and servicing of monitoring equipment. :ate cenift►ation or mport trust be prem for each monitoring system control panel by the technician who performs the work. A copy of dus form roust be provided to the Luck systetn ownevIoperator. The owner/operator must submit a copy of thus form to the local agen�- r"Wating CST syscems within 30 days of test date. A. General Information Facilitv Name: >'ycC �zi L' -- Service Station No. i Site Addrms: City: zip: Facility Contact Person: �'�q C.: Contact Phone No.: S 4 - ---- M6&Modef of Monitoring System: 1 ZZ S q leu 1 Date of Tesft*Servrc-- 3 B. Inventory of Equipment Testted/Certified Check the apprepriaw boxes to indicate specific egmpment in serviced: Tank ID: / del Tank ID: u1}`t:urk Gauging Probe: Model: C1n-Tank Gauging Probe: Model- Lt-'I��A��mrlar Space or VmAt Sensor: Model: f� i OAnnuiar Space or Vauii Sensor Model: ( 4rjng Sump Trench Sensor(s): Model: '� �' ❑Piping SumptTrench Sensor isy 'Model: ❑Fill Sump Sensor(s): Model: OFill Sump Sensor(s): Model: []Mechanical Line Lek Detector. Model: ❑Mechanical Line Leak Detector. Model: OF Line Leak Detector Model: ❑Electronic Linc Leak Detector Model: ,JPctronwante Overfill/fligh-level Sensor: Model: l -/-1 4-S ❑Tank OverfilI/tfigb-level Sensor- Modek ❑Other, specify type and model in Section E on Page 2 ❑Other, Specify e mp. Mx and model in Section E on Page 2 Tank ID: Tank ID: Oln-Tante Gauging Probe: Model: _ Oln-Tank Gauging Pwbe: Modei: ❑Annular Space or Vault Sensor Model: OAnnWar Space or Vault Sensor Model: ❑Piping SumpTrench Sensor(s). Model: OPiping Stmprrrench Sensor(s): Model: []Fill Sump Sensor(s): Model: ❑Fill Stump Sensor(s): Model: ❑Mechanical Line Leak Detector. Model: — QMechamcal Line Leak Detector, Maori: QElectronic Line L=k Detector Model: ❑Electronic Line Leak Detector Model: -- OTank OverfiWHigtt-level Sensor: Model: OTank -Level Sensor. Model: COthez, Specifv equip. r ype and model in Section E on Paw 2 ❑Other. Specify eqmV. qpc and model.in Secrion E on Page 2 Dispenser ID: Dispenser ID: ❑Dispenser Contwunient Sensors: Model: []Dispenser Conu nunent Sensor(s).' Model: — —i ❑ Shear Valve(s). ❑ Shear Valve(s). CjDispenser Containment Float(s)and s) []Dispenser Containment Fl s)and Chain(s) Dispenser ID: _ Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: Q Shear Vatve(s). O Shear Valve(s), ODiTenser Containment Float(s)and Chain(s) ElDispenser Containment Float(s)and s Dispenser ID- Dispenser ID: !]Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: D Shear Valve(s). O Shear Vatv+e(s). ODispenser Comainmem Float(s)and Chain(s) ODispenser Containment Float(s)and Chain(s) 'If the facility cocamns more tanks or dispensers.copy this form- Include inibmiLatum for every tank and dispenser at this facility. C. Certifiestion - 1 certify that the wMipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (r-p, manefactarers' cbeddists)necessary to verify that this information is correct and a Ptot Plan showing the layout of monitmUg equipawnt. For any equipment capable of generates such reports, I have aho attached a copy of the report; (ckeck ail tko[apply): O System set-up 0 Ala to rgwrt Technician Name(Print): Ed Stearns Signature: � Certification No.: % )7-,( License No.: Testing Company Name: Champion Precision Testing Phone No.: (916)927-1557 _