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MONITORING SYSTEM CERTIFICAON For Use By All.Iurisdictions Within the State of California 3, Tite 2 , Califoa Code of Regulations Authority Cited. Chapter 6 7, Health and Safety Code; Chapter 16, Division certification or This form must be used to document testing and servicing of monitoring equipment.lA 3separate rnireVg�must form ur ovi I vanel by the technician who performs the work. A copy of this 0 ich rin control ORM to the tank system.owner/operator. The owner/operator must submit a copy of this form to the local agency re within 30 days of test date. JUL S 0 2007 A. General Service Station No.: M- - A- H Facility Name: tMVIF H'L Zip: P E RMTT/-:)'--R V I E-S Site Address: city: T, C-( - Facility Contact Person: Contact Phone No.: Makefflodel of Monitoring System: IAZl Date of Testing/Service: B. Inventory of Equipment Tested/Certified Info Check the MgMriate boxft to indicate MECificgMment His meted/serviced: ey.7 Tank ID: T=11D: 4-f Model: /z;// -Tank Gauging Probe: -Tank Gauging Probe: Mode]: Oln 02(flnular Space or Vault Sensor: Model: Lrf �-L 0 A nnular Space or Vault Sensor Model: Sensor Mode 77,1 ug SunWrrench Sensor(s): MOW: C Mping Sump/Trench (s): 1: OF111 sump Sensor(s): Model: OFill Sump Sensor(s): Model: 'JP OMechamcal Line Leak Detector. Model: Mechanical Line Leak Detector. Model: L10 10"0 2 E3EIectronic Line Leak Detector Model: OElectronic Line Leak Detector Model: OTank Overfill/High-level Sensor: Model: OTank Overfill/High-level Sensor: Model: OMSL_S�!9!�R.=and model in Section E on Page 2 00ther,S22�&20t- =and model in Sectij=B on ElaM.2 T 'D /Z '<�! S,T- Tank ID: Vrl Gauging Probe: Model: P 1fOln-Tank'Gauging Probe: Model: OAnnular Space or Vault Sensor- Model: i,5 OAnnular Spam or Vault Sensor Model: gpipin Sumpffmich Sensor(s): Model: LA0' OPiping Sump/Trench Sensor(s): Model: E3FW Sump Sensor(s): Model: CIFill Sump Sensor(s): Model: cal Line Leak Detector. Model: rt3Mechanicat Line Leak Detector, Model: OEectronic Line Leak Detector Model: 011lectronic Line Leak Detector Model: OTank OverfEffigh-level Sensor: Model: OTank Overfill/High-level Sensor: Model: Ootberllmft 2M!R.!XM and model in Section E on Page 2 00ther,§ and model in Section E on EM 2 Dispenser ID: ) .,Q- 2- Dispenser ID: 7 -(-( ODispenser Containment Sensors: Model: 1—LUL— ODispenser Containment Sensor(s): Model: E3 Shear Valve(s). 0 Shear Valve(s). [32isMn Containment Float(! and Chains ODi!Mnser Containment Fl2 and Chain s) Dispenser In Dispenser ID: ;7— 9' ODispenser Containment Sensors: Model: I-) jI ODispenser Containment Sensor(s): Model: '14 0 1� 0 Shear Valve(s). 0 Shear Valve(s). Mlspenser Containment Fl s)and Chairs s [3Dispenser Containment Eoa .As2 and Chain q Dispenser ID: Dispenser ID: ODispenser Containment Sensors: Model: ODispenser Containment Sensor(s): Model: 0 Shear Vah*s). 0 Shear Valve(s). ODispenw Containment Float(s)and Chains ODispenscr Containment Floats)and ChainLs) *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 idIentlfled 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 coof theor:t (, an that apply): 13 System set-up U p h' ort u -re2 , (cheek Technician Name(Print): Y/ r-hs Signature: Service Technician No. 525 0 Y Certification No.: License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (661) 363-7400 Pswe I of 3 - 03/01