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9 1 MONII ORING SYSTEM CERTIF CATION For Use By All.Jurisdictions Within the State of California rl uthority Cited.• Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This 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 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: i ., /d/ T7"[; Service Station No.: Site Address: G' ✓ �y(/x/ City:_:Zz;�E e -� Zip: Facility Contact Person: _f �« �,.r Contact Phone No_: L1�1��f3- Make/Model of Monitoring System: ,-t ?f men-/ Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check-the at) ropiiate boxes to iadicate sQ ific egaipment inspected serviced: 1lTank ID:- Tank ID: j [-11n-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: O'Annular Space or Vault Sensor. Model: []Annular Space or Vault Sensor Model: :zIli'sl SumplTrench Sensor(s): Model: ❑Piping Sump/Trench Sensor(s): Model: ump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: []Mechanical Line Leak Detector. Model: 1 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: _ ❑Electronic Line Leak Detector Model: OTank Overfill/High-level Sensor. Model: ❑Tank Overfill/High-level Sensor. Model: ❑Other, S ui and model in Section E on Pa e 2 ❑Other. S t)pe and mode! in Section E on Pa,c 2 Tank ID: Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: ❑Annular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: ❑Piping Sump/Trench Sensor(s): Model: ❑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 Overfrllf igh-level Sensor. Model. ❑Tank Overfill/High-level Sensor: Model: ❑Other,S : and model in Section E on Pa 2 ❑Other, S _ ui . t and model in Section E on Page 2 D - r ID. Dispenser ID: - - ❑Dispenser ent Sensors: Model- ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear V alve(s). ❑Dis nser Containment Float(s) (s) ❑Dis nser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). Valve(s). OD!Nnnser Containment Floats)and Chain(s) ODispenser Float(s)and Chain(s) Dispenser tD: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Di ) spencer Containment Sensor(s): odel: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑D user Containment Float(s)and Chains ❑D' user 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. 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(eg.manufacturers' checidists)necessary to verify that this information is correct and a Plot Plan showigg the layout of monitoring egaippmt. For any equipment capable of generating such reports,I have also attached a copy of the report,(check all that apply)_ Sp F C h' ory report Technician Name(Print): Keith Huston Signarwr-: - Ceriification No.: cle e—U S' Z P--,;, License No.: Testing Company Name: Champion Precision TestingInc _ Phone No_: (916)927-1337 Paan 1 of 3