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MoNrrORING SYSTEM CERTIFICATIO For Use By All.lurlsdictions Within the State of California Re lations • Authority Cited: Chapter 6.7, Health and Safety Code. Chapter 16, Division 3, Title 23, California Cine oaf or �rt � be document testing and servicing of monitoring equipment. A�fi This foam must be used ng system control —1 by the technician who performs the work. A COPY ofthis luting UST systems form must be prmided to the tack syr' awlrtr/oP'° The owned r mural submit a oopy of this form to the local agencyregu within 30 days Of test dale - A. tt enersl informatig,a Service Station No.: Facility Name: t'_'iGifr fn c'� City: � �7 � Zip: ss: Site Addre Facility Contact Person: y Contact Phone No.: Date of Testing/Service: MakcJModel of Monitoring System:,,,�r-r � B. Inventory of Equipment Tested/Certified Dispenser ID: _ `C � ispenser Containment Sensor(s): Model Shear Valve(s). Shear Valves)9 F1 s and Chain s Cbecic riate bo3m to Indicate egm • Dispenser ID: Containment Sensor(s): Model: _ 10 Shear. Valve(s) Shear Valve(s). Tank ID: ODi Containment Flocs and C s T ID: _FC 7MOde1: ank Ganging Probe' - c Oln-Tank Gauging Probe: Model:_ Model: 2 `e space or Vault Sensor: Sensor (s): Model: q el d - Ort Model: _ OAnnular Space or Vault Sensor Mping Sump/Trench Sensor (s) : Model: L� � � ? YDS ' I Sump/Trench Model: ®Fill Sump Sensor (s): Model: OM Sump Seng (s)• 6fieclianical Line Leak Detector, o•t Model: S°T"t° P OM echanical Line Leak Detector. Model: ! tam 0 OElectronic Line Leak Detector Model: OElect+onic Line Leak Detector []Tank t?verfill/I�igh-level Sensor: Model: Model: OTank OverSll/lligh-level Sensor: Model: and model in Section E on 2 OOther, S and model in Section E on Pa 2 ® S T 19): - i Tank Gauging Probe: Model: At a- t Tank ID: Oln-Tank Gauging Probe: Model: - Space or Vault Sensor. Model: 0 - r 6 ` L Annular Space or Vault Sensor Model: Model: SumplTrench Sensor (s): Model: 7 - ' OPiping Sump/Trench Sensor (s): Ordl Sump Sensor (s). Model: OFill Sump Sensor (s): Model: Model: Lim leak Detector. Model: L 0 Zags w OMechanical Line Leak Detector. Line Leak Defector Model: ®Electronic Line Leak Detector Model: []Electronic C3Tank Overft Mgh-level Sensor: Model: OTank Overfill/Mgh-level Sensor: Model: S and model in Section E on r,na,or qmv ifv eanin. tune and model in Section E on Page 2 00ther, Containmuet►t Sensors: Model: Dispenser ID: _ `C � ispenser Containment Sensor(s): Model Shear Valve(s). Shear Valves)9 F1 s and Chain s ODi nser Containment Floats and Chain s) �• ID: Containment Sensors: Model: Dispenser ID: Containment Sensor(s): Model: _ 10 Shear. Valve(s) Shear Valve(s). Containment Fl s) and Chains ODi Containment Flocs and C s .spexim ID: Dispenser ID: ODispenser Containment Sensors: Model: [!Dispenser Containment Sensor(s): Model: Q Shear Valve(s). O Shear Vah*s). rolsomm Containment Float(s) and Chains ODiResa Containment Floats and Chain(s) *lithe f lily conW= 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 carred and a Plot Plan showing the layout of monitoring equipmext. For any equipme capable of generating such reports. I have also attached a co o rim rv. (check all that apply): System set-up h• rt Technician Name (Print): 4C r- hs Signature: Service Technician No.: C? Y Z Certification No.: €( License No.: Testing Company Name: Champion Precision Testing, Inc Pbone No.: (661) 363-7400 _ Pave 1 of 3 03101