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MONIPORING SYSTEM CERT14ATION For Use By A11.Iurisdictions Within the State of California Authority Cited: Chapter b.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 report must be prepared for each monitoring system control panel 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. GeneralInformm5tion 90�. Facility Name: /..,^ J Service Station No.: Site Address: Z4� 72�,We-ge ex/a City: ,� Zip: Facility Contact Person: „��' Contact Phone No.: Make/Model of Monitoring System: j/ j—:�,5 _� � Date of Testing/Service: B. Inventory of Equipment Tested/Certifed Check thea ro riate boxes to indaeMS s ecific a ui anent" serviced: [! Tank ID: Tank ID: , Eln-Tank Gauging Probe: Model: E n-Tank Gauging Probe: Model: [ Annular Space or Vault Sensor: Model: FTAnnular Space dr Vault Sensor Model: JRPiping Sump/Trench Sensor(s): Model: t9OPiping Sump/Trench Sensor(s): Model: ,W-1.7p ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: QMechanical Line Leak Detector. Model: 04 Z7,-L,6<7a 93Mechanical Line Leak Detector. Model: '40.6> ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, S !i and model in Section E on Page 2 ❑Other,S tc and model in Section E on Pa e 2 Tank ID: Tank ID: �- On-Tank gauging Probe: Model: / Mfn-Tank Gauging Probe: Model: ,0" p'Anrrular Space or Vault Sensor: Model: j' 0= C9'Annirlar Space or Vault Sensor Model: „ 01 iping Sump/Trench Sensor(s): Model: 22 y 3'0• "ping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: pMechanical Line Leak Detector. Model: ,gyp 0 011rAechanical Lute Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Over-lill(High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: -- ---_._ ❑Other, S ui . and model in Section E on Pa e 2 ❑Other, S ui . and model in Section E on PKC-1,2 Dispenser ID: x Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: UkShear Valve(s). C4`hear Valve(s). �d user Containment Floa(s)and Chain(s) ❑Di user Containment Floats)and Chains) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: odeh: ❑Dispenser Containment Sensor(s): Model: C9�S�hear Valve(s). ❑ Shear Valve(s). ! nser Containment Floats)and Chain(s) ❑I)i nser Containment Float(s)and Chains) Dispenser iD: Dispenser ID: []Dispenser ContainmentSensors: Model: ❑Dispenser Containment Sensor(s): Model: 'Shear Valve(s). ❑ Shear Valve(s). (moi nser Containment Float(s)and Chains) 01)iEpenser 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 gb manufacturers' checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the repo t;(chrzk all the 4pply): v`g*stem s jkcerahistory report Technician Name(Print): Keith Huston Signature: Certification No.: A �� License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (916) 927-1557