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ONI Rltii iGSYSTENI CERTIFATIQN �� For Use &y All Jurisdictions Within the State of California ?/DD Authority Cited: Chapter 6.7, Health and Safety Code: Chapter 16, Division 3, Title 23, California Code vgglat'ons This form must be used to document testing and servicing of monitoring equipment. A se arate certif i n or r$ be prepared for each monitoring_ system control panel by the technician who performs the work. A copy of this, provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency hr within 30 days of test date. A. General Information Facility Name: KW 1 K Service Station No.: Site Address: 95 0 L,) , I T7, 5; T City Zip: _'?,5 3-7 6 Facility Contact Person: ¢Z Contact Phone No.: c-�17� Makeli+rtodel of Monitoring System: "j -L; - -5 Z Date of Testing/Service: l ole B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectedtserviced: j Tank ID. /- -- Tank ID: 3 - ges, C -4"z- -Tank Gauging Probe: Model: 2Tn-Tank Gauging Probe: Model [nular Space or Vault Sensor: Model: -7fq�d - y-67 pular Space or Vault Sensor Model: 72_,�eC E115i-ping Sump/Trench Sensor (s): Model: 2Ptptng Sump/Trench Sensor (s): Model:-77cE-3TZ�-2 i]Fill Sump Sensor (s): Model: DFill Sump Sensor (s): Model: ❑Mechanical Line Leak Detector. Model: []Mechanical Line Leak Detector. Model: 2E1ectronic Line Leak Detector Model: c, ,� 2 90ectronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: DTank Overfill/High-levet Sensor: Model: 00ther, S eci a ui . !m and model in Section E on Pae 2 []Other, SpecaSquip. t and model in Section E on Pae 2 Tank ID: 2 - ,- ft' Tank ID: Ern --Tank Ganging Probe: Model: /'(. - ❑ln-Tank Gauging Probe: Model: Q7lnnular Space or Vault Sensor. Model: -7 leo 7 []Annular Space or Vault Sensor Model: C�ping Sump/Trench Sensor (s): Model: -7V 't- _.;zz []Piping Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): _ Model: ❑Mechanical Line Leak Detector, Model: DMechanieal Line Leak Detector. Model: BElectronic Line Leak Detector Model: DElectronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-Ievel Sensor: Model: pother, S 6 aqui a and model in Section E on PaLe 2 pother, S ecif equip. and model in Section E on Pay=e 2 Dispenser ID: l - z Dig enser ID: -7-7 B`fSspenser Containment Sensors: Model: '7 7 i ' Mispenser Containment Sensor(s): Model: � CTighear Valve(s) 6 Shear Valve(s). ElDispenser Containment Float(s) and Chain s) 013is enser Containment Float(s) and Chain(s) Dispenser [D. ? - Dispenser ID: 3flispenser Containment Sensors: Model: '7'7y-7 []Dispenser Containment Sensor(s): (Model: Q'Shear Valve(s). p Shear Valve(s). ElDis nser Containment Float(s) and Chain(s) 013ig2nser Containment Float(s) and Chain(s) Disp nser ID: !--AL Dispenser 1D: • ispenser Containment Sensors: Model:- ❑Dispenser Containment Sensor(s): Model: 3"Shear Valve(s). [] Shear Valve(s). _ QDispenser Containment Float(s) and Chain(s) []Dispenser 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 Piot Plan showing the layout of monitoring equipment. For any equipment capable of ;eneratina such reports, [ have also attached it copy of the report; (check all that apply): stem set-up -J larnt history ep @ Technician Narne (Print): YJLV t N L, At lL6-t.lt N Signature - Service Technician No.: T" — Certification No.: 7Y _ _ License No.: -�--- Testing Company tiame: Champion Precision Testing, Inc Plione No (F>f> E ) 363-7400 Page t of 3 - 0310 r