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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Stale of California Authority Cited. Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, 771tle 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 prepared for each monitoring Ustem control mad 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: AL4,Z, AS �,. 0 Service Station No.: Site Address: 'i�9 ' C l�' s`T City: c zip: ;��" Facility Contact Person: M A �-/ -e. k Contact Phone No.: 10- Mak dModel of Monitoring System: u& -cd C -goo - 1-7-L5' 3 5'0 Date of Testingiservice: 9 -2.Z- B. 2.Z B. inventory of Equipment Tested/Cer ifled Check the appropriate boxes to iudrente specific equipment insoected/serviced: Tqk ID: c- e Tank Gauging Probe: Model: , t T ID: Tank C urging Probe: .Model: Jfi i4 6-1 e Space or Vault Sensor. Model: d Space or Vault Sensor ModeL 6,,?9 y_ 0 •i6 9/ g SumplTrench Sensor (s): Model: C,2-9 4 _71a, 2pfL Sump/Trench Sensor (s): Model: 4 5,7 q qjl" ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: O,Vlechanical Lines Leak Detector. Model ElMechanical Line Leak Detector. Model: ELL Q Etectrouic Litre Leak Detector Model:Eklectronic Line Leak Detector Model: ❑Tank OverfilUHigh level Sensor: Model. ❑Tank Overfill/Higirlevel Sensor: Model: OOther, S and model in Section E on Page 2 ❑Other, &=& equip DZ and model in Section E on 2 Tank ID: 3 — Cyr ? Tank ID: efjn-Tank Gauging Probe: Model: ❑ln-Tank Gauging Probe: Model: dar Space or Vault Sensor. Model: d t ' C 6d " ❑Annular Space or Vault Sensor Model: U��►rm ping SumplTrench Sensor (s): Model: d. 2G " ❑Piping, Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ElYwhanical, Lime Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: [AE]ecbwk Line Leak Detector Model: PLUO ❑Electronic Line Leak Detector Model: ❑Tank Overfiil/High-leveI Sensor. Model: ❑Tank Overfill/High-level Sensor: Model: 02t3rer and model in Section E on Page 2 (]Other Specffy Ma. DE and model in Section E on EM 2 Dispenser ID: Dispenser ID: 24- e( ❑Dispenser Containment Sensors: Model: 211 ❑Dispenser Containment Sensor(s): Model: c� ❑ Shear Valve(s). ❑ Shear VValve(s). ODLqpcnser Containment Floats and Chains ❑D" Containment Floats and Chains) Dispenser 1D: Dispenser ID:' ❑Dispenser Containment Sensors: Model: 2 cl = ❑Dispenser Containment Sensor(s): Model: i Ci ❑ Shear Valve(s). ❑ Shear Vak*s). ODLvenser Containment Floats) and Chains) ODbpenser Containment Fl s) and C s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: []Dispenser Containment Sensor(s): Model: ❑ Shear Vaive(s). ❑ Shear Valve(s). ODispensa Containment Float(s) and Chains) OPNEMContainment Floats) 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 cation - I certify that the equipment identified is this document was inspectedlserviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (eg. manufacturers' checklists) necessary to verify that this information is correct and a Piot Pias showing the layout of monitoring egnipm"t. For any egnip pahte of generating such reports, I have also attached a cog aithe report; (check all thda apply)- iarsysicia get-up FT report Technician Name (Print): Signature: Service Technician No.. Lk 7` e Certification No.: 17cf 7 License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (661) 363-7400 Paee 1 of 3 03/01