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For Vw.j3v,411.Iurisdiarions Within rhe State of Cah/j)rrua Authorav C�ired:Chapter 6.7, Health and Sarety Code: Chapter 16, Division:i, '.r tie 23, ( aider a Code af'Regulapons This form trust be used to docioltent testing surd scNicing of trtoniiorinb equipment, A seuarate Gertiliguon Qy t�Ft must be [ 1h5 each MOJUU tit=b7t3 M G4gtKjjW= by the techniemn who perfmim the work. A copy of this form mast be provided to dle Umk system o'► nerloperator. The owuet'/operttor muse subujit a copy of ttm form ro tGr local agency reguiaang USl'sysumis within 30 days of test date. A. General ;information Facility Nano: - �rOeC, V/ Service Scarier No. Sitc Address: % G..Y �� Cita' _ ��'C�_ Zip: — Facility Contact Person: _ _ Contact Phone No.: Z rZ_ r7 < __ .. !vtAkelModei of Mowtmng System: //i11��U' dG'o _ Date of Te=wsesvi,7-!• B. Inventory of Equipment Tested/Certified Check dee elute bow to indkxic iftcMeow rtr serviced.- TaNcLD: dD serviced.- Tank Ol Tank Gauging Probe: Model: _ Tank Gauging Probe: Model: �rruitu Space or Vault Sensor: Model: �� i � OAnuu ar Space or Vault Seasar Model: ping SumplTreach Sensor(s): Modal: �S (]Piping Sump!!'refuch Sensor(s)' INocitl: OHII Sump Srnsru(S)' Mattel: ❑Fill Sump Sensor(8)' Model: ONlGl:hwacal Line Leak 11,neaor, Model: IlMechamcal Line Leak Detector- Model: OO�tlic Linea e Lk DctNietor Mow: QElextrot is Linc Leak Detector Model: ank Overfillllli 04evel Sensor: Model: 7r)9—'WLT131'ank Overlill/Higb-level Sensor: Model: OOtlttcat S and model m Stenon E on Z CJC)ther S ui . :rad model in Section E ori Pa 2 Tank ID: Tank ID: GlnTank Gauging Probe: Model: Olu-Taal[ung Probe: Mode►' OAnnrrlar Spam or Vault Sensor: Model: 0Annular Space or Vault Sensor Model- OPiping SumprTrcuch Sensor(s): Madel: [piping Sumpn)mr Sensor(s): Model: C]Fdl Scarp Sensor(s): Model: ElFill Sump Sensor(s): Model: OMechanical Litre Lash Detector. Model: UM=hamcdl Line Leah Dac=- CIElocaunic Line Leah Defer T Model: ClUe ironic Line Leak Detector Model. _— OTauk OvertilUHigh-level Sensor: Model: OTank OvaJWHigb-Ievel Sensor. Model: 00ther, S tad wodel in Section E on Pa 2 ❑t�rber S and model vn Section E on 2 Dispenser ID: DiWcv=ID: (]Dispenser Cont-ainment Sensors: Model: ODisp==Conte Sensor(s): Model: 0 Shear Vah*s). 0 Sbtar Valve(s). ❑Di r Conuiuiaw t.FI s)and s) ❑ Con=mcut FI s and C s D7bpeaw LD' Dispenser ID. ❑Dispenser Comainram Sensors: Model: !Dispense'ContzautwW Sensor(s): Model: 0 Shear Vaive(s), 0 Shear Valve(s), C] Corrtairunetu Floats and Chain"s QD Conra®ment F1 s anti Cbai s bispemser ID: iEl Dispenser ID' ©Dispenser Containment Sensors: Model: ODispea'ger ContainmeW Scnsor(s): Model: C] Shear Valve(s). O Shear Valve(s). DD' neer Containment Float(s)and C s ODL4 r Grnntainment Float(s)mild s *If the anility contai m more inn lc5 or dispcwwxs.copy this form- include informum for every tank and dispenser at this facility. C. CertifUZtion - I ca-aly that the equipmMs ideadned is this docununt teas itssPvcW&servi=d is accordance 'With rhe trmanufatturer3'guidelines. Attached to tW Certificatko is information(e.g, manp(actamn' choddlau)D oona/y w verily Illi gill information is cornea and a Plot Plan sbowing the layout of mmtonxg equipment. For any equ4mwat capable of Bvacreaft such relwrht.I bare titan stowbed y copy of rho report; (dwa ail cloy arpp&' Q Sysoem sei-up ° 3 �� Technician Nance(Print): Ed Stearns Signature: Certafcatiou No., L=E=No_: Testing Company Name: Champion Prema-an T Phone No.. (916)927-1557 LB/Z0 d9dd 9NIlShc NOIdWdHO bLbL696T99 TS :ST 900Z/6T/90