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NI G SYSTE-M CERTIFIWtION For Use 4vA11.1urisdictions 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 retort must be prepared for each monitoring_ system control paiiel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator most submit a copy of this form to the local agency regulating UST systems within 30 days of test date., A. General Information Facility Name: 4kl /se,n g�� Service Station No.: Site Address: '41'3T City: �-cf� Zip: Facility Contact Person: S'r / r ,d� P�/�-,r Contact Phone No.: Make/Model of Monitoring System: ld¢ i - Date of Testing/Service:1,9—IR-05 B. Inventory of Equipment Tested/Certified Check the worooriate boxes to indicate specific _equi�meut iimWected/serviced: hi Bln-Tank Gauginj Probe: Model: 12%mmlar Space or Vault Sensor: Model: OPiping Sump/Trencho t♦ 4 ,OFiU Sump Sensor (s): Model: ORMechanical Line Leak Detector. Model: -572P ■ # t4 Detector tt []Tank Overfillfiligh-level Sensor: Model: in. vEt'and model ` I Section E oz. .: Oln-Tank Gauging ':#t•Model: Tank ID: OAnnular Space or Vault Sensor Model: �'i ■' t t I,t r ` tc ■ Sump Sensor (s): Model: �I OMechanical Line:aDetector. Model: OElectronic Line Leak Detector Model: IOTank Sensor. Model: 94Jh-level. f e Zh_► " #Overfillffli- Y me and r I I # 4: ' 1 Section E on Page Tank ID: Tank ID: 99b -Tank Gauging Probe: Model: g 7 Oln-Tank Gauging Probe: Model: alar Space or Vault Sensor: Model: Y pcf ' []Annular Space or Vault Sensor Model: OAping Sump/Trench Sensor (s): l: - OPiping Sump/Trench Sensor (s): l: Sump Sensor (s): iso OFill Sunup Sensor (s): Model: [Mechanical Line Leak Detector. Model: / OMechamcat Line Leak Detector. Model: []Electronic Line Leak Detector Model: OElectcomc Line Leak Detector Model: []Tank OverfiiUHigh-level Sensor: Model: OTank OverfilMgh-level Sensor: l: S amodel in Section E n Pe t []Other, S[]Other, and model in Section E on P 2 Dispenser ID: Dispenser ID: pDispenser Containment Sensors: Model: ff J;" nser Containment Sensor(s): Model:p/�" e 2,Shear Valve(s). [hear Valve(s). OD' user Containment Floats and Chain s2 og!MEE Containment Float(s) and Chain(s) Dispenser ID: „7,fl Dispenser ID: goispenser Containment Sensors: Model: ,� '�j - ✓930ispenser Containment r(s): 1: Valve(s). lrahear Valve(s). ODispenser Containment Float(s) and Cbain(s ODi Containment Float(s) and Chain(s) Dispenser ID: j— Dispenser ID: [gMspenser Containment Sensors: Model: so* ODlspenser Containment Sensor(s): Model: grghear Valve(s). O Shear Valve(s). E]Dismnser 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 Plot Plan showing the layout of monitoring eqmpTenj Fo&anyequ�ipme capableof generating such reports, I have also attached a coy f the po (check all that apply): Systema h' ory report Technician Name (Print): , � Signature: Service Technician No.: '. " cs f Certification No.: ped- License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (661) 363-7400 Paee 1 of 3 03/01