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MONITORING SYSTEM C:E 11FIC;.A'9:'IQ.IN <br /> For L'se ByA11 ArWicilorts Within the State of California <br /> Authority Cited: Chapter 6.7, 1-1;aith and Safety Code:Chaptar 16,Division 3, 77rle 23, Calffornia Code ofReguiurdans <br /> This form mw be used to doeimu= besting and sexwiciug of monitoring equipment. A setracate certification or report MIM.l& <br /> oppygmd for=0 m4dioriuxS slum wnuul by the tocJimcum who peEorma the work. A copy of this Boron mist W provided <br /> to the tank system ownedoperator. The owner/operator mad submit a copy of this form to the local agency regulating UST systems <br /> within 30 days of-test dale. <br /> A, Genera!Information <br /> Facility Nam: ��lf 1�C. ...����/ Service Station No_: <br /> Site Address: 17 City: zz <br /> Y <br /> Facility Contact Pemon: Contact Phone No.: <br /> NtrikefModal afMoiiitorxng System; Z �-S s s Date oaf Testi*Service, Zd•-q—O`( <br /> R. Inventory of Equipment Tested/Cerdried <br /> Cmc the rixte boxes to indleaft sEEE&eauioment' servkeda <br /> TkTS <br /> t� E'�-- T 1D: <br /> Gauging Probe: A&DW: 1W— ••Tank Gainog Probe: Moftl: r- t <br /> Space or'Vanit Sensor; Modd: 1R �-4&.2 �ar Space or Vault Sensor Abdel: t"4..�-O <br /> am fll"retach Serasacr(s): Model: `FI— ping Sicmp/Trench Serasnr(!r): Modes= cs79(ils"�o -24� <br /> ORR sump Sensor(a): Model: ©Fill Sump Sensor(s): Model; <br /> O Live Leak Detector. !Model: 5t�me.Leak <br /> lane Umk Detector. Mode: <br /> ®� Line Leak Detector Model; O Detector Model: , a'C <br /> [!Tank ll�gb.-ievel Sensor: Model: CJT: Ove�ltlHigh evel.Sensor: Model: <br /> ©�Othsr.S ui . sent model ztt Section E on 2 C1C�t3ar .r, S. and model in Section E Ott ft C-2 <br /> T�a'7nl�c 1D; -2 Tank ID- <br /> M, "f=*Ganging Probe: Model: & flim-Tank Gaaiging Robe: Model: <br /> S[ Space or Vv t Sensor: Model b- OAtitaalw Space or Vault Sensor Model: <br /> umpil'rens lh Seasor(s): Model: Rbrza ©piping Sumpfriench Sanson(s): Model: <br /> Sump Sensor(5): h1odd. 0 FiU Sump Sensor(s): it mel- <br /> chnnical Lithe Leak Deteetor. Model: (jMec�tical Line Detector. Model' <br /> »r+ot�ic Line Leak Ddedarr Model: t'LL ClEjecUonic Line Leak Defector Madel: <br /> OTank OverSilUOO-level Sensor: Model: [!Tank Ovafiitl flgh-level Sensor: Mod&: <br /> 0Other,§Rect awip. and sande!in Section E on 2 ❑Other,S and model iia Seadon E on 2 <br /> llisAens�r 11J: Djapeu t ID: <br /> oDispenser Comaimam Sensors: Model: _ ,Y ClDcspen=Containment St WOf(S): -Modei; <br /> O Shear Valve.(%). © Sbm Valve(s). <br /> ContaiUMMt Floii s)and Cham(s) Contaiment!+'lost s)suet Chain(s). <br /> Di ID: -* <br /> Dispenser ID: <br /> []Dtq msec Caniw==t Sensors: Model: ODiWmur CUufiliililiitit Scn�s): Maid: <br /> [I Shm Vaive(s). ! Shear Valve(>;). <br /> pD' Canuigment Floc s)and Cbain s:) MDjbv==Containment F s and Chain(s) ._ <br /> Dispenser W: Dispenser ID: <br /> ©Dispe =Conwiamen Sensors: Modd: []Dispenser Canitaim�Sensor(s): Model: <br /> ❑S-hear Vah*s), O Shear Vaive(s). <br /> ©D• Containment Fioat(s)mid Chaiu(s) Containment Float{s)aero Cbnin(s) <br /> "Il:Ute Wmy conblltts more tames or d4m=is,copy tbas form Yncludo information for every tsukk and dispenser at this Facility. <br /> C. Certiftation - I cer4ty that the equipment idsntiaed in tints document was inspedeNserviced in accord wee with the <br /> mmufacturers,gmdehw& Azzachea w ihn Cerrii[catius tar Wurmotion(a C, uaanmfarcturv", ck.:&ittists)uaepw2ry'to ver4 Char thin <br /> information is correct and v!Piot Plan sbowing the layout of monitoring equip or yOy gq*wevseapable of generating Buda <br /> repairs. [hank ulscr attacited u copy of the report; (check ail that dgpk) slystm <br /> set-up 'oto ............ <br /> Technician Name(Print): ` r' Suttee: 1 --� <br /> Certification No.: rl Lice No.. <br /> Tesang Couq=y Name: Champion P,* cision Te!ljn%Inc Phone No.: (916)W-7-1557 <br /> p�lase 7 of 3 riRnal <br /> Z0 30dd 3Ad3SAIM>i Z90ZZ686OZ 9Z:170 b00Z/8Z/0Z <br />