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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority 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 RLepMd 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: /ICIK/i Service Station No.: Site Address: city: 7-91-?C51 Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: 2rLe, Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check the!"EgILA:ate boxes to indicate Necific EE!pinent ins mcted/serviced.- T ID: V1CPC Z— T ID: �-L. 17 Tank Gauging Probe: Model: M AJ--t Gauging Probe: Model: Space or Vault Sensor: Model: 7?qj1F6-402 ular Space or Vault Sensor Model: 7M'fd e(O 2 ng Sump/Trench Sensor(s): Model: e7lir,716-2_46' g Sump(rrench Sensor(s): Model: c;�IFVTO--Zd6' OFill Sump Sensor(s): Model: OFUI Sump Sensor(s): Model: 0 Model: ON)echamcal Line Leak Detector. Model: e ,cc ,=cal Line Leak Detector. Ulf-lectronic Line Leak Detector Model: 01LO onic Line Leak Detector Model: L3 j,4-L2 OTank OverfillIffigh4evel Sensor: Model: 0Tank Oveilillffligh4evel Sensor: model: 00ther, §g2�ft Sm 2ge 2 noth" §R��a STIR�� �g.pT�and model in Section E on P and model in Section E on Page 2 T 11D: 3 8-2 Tank ID: 7 .ank Tank 97, Tank 4 milar aping S -Tank Gauging Probe: Model: Kk a Oln-Tank Gauging Probe: Model: Space or Vault Sensor: Model: ]Annular Space or Vault Sensor Model: Piping Sump/Trench Sensor(s): Model: b-7qq34b-Z0jK OPiping Sump/Trench Sensor(s): Model: Sump Sensor(s): Model: OFill Sump Sensor(s): Model: chanical Line Leak Detector. Model: oMechanical Line Leak Detector. Model: Ele Electronic Line Leak Detector Model: tP4,i_0 OElectronic Line Leak Detector Model: OTank Overfill/High-level Sensor. Model: OTank Overfill/lUgh-level.Sensor: Model: 00ther,§ and model in Section E on Page 2 00ther, §pEft and model in Section E an Page 2 Dispenser ID: Z. Dispenser ID: 51-t-q ODispenser Containment Sensors: Model: IZ6k ODispenser Containment Sensor(s): Model: 0 Shear Valve(s). o Shear Valve(s). ODispenser Containment Float(s)and Chain s) OD! Containment Float(s)and Chain(s) Dispenser ID: Dispenser U): 5�iw ODispenser Containnicitt Sensors: Model: 1-6 f5r 00ispenser ConLainment Sensor(s): Model: 0 Shear Valve(s). 0 Shear Valve(s). ODispenser Containment Fl s)and Chain s) pDisEnser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: 013ispenser Containment Sensors: Model: ODispenser Containment Sensor(s): Model: 0 Shear Valve(s). 0 Shear Valve(s). ODLContainment Float(s)and Chain(s) oRigngser 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(e.g. manufacturers' checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipmeot-'For any equipment'apable,of generating such reports, I have also attached a copy of the report; (chec*all Aw appiy): i!ffystein set-up 12'Alh arm jsto Technician Name(Print): Signature: Certification No.: rl Z_ License No.. Testing Company Name: Champion Precision Testing, Inc Phone No.: (916)927-1557 P-A&P.1 Of.3