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ONITO G SYSTEM CERTIFIC ION For Use By All Jurisdictions 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 seuarate certification or tel?ort must be QreRjaach monitoring system control panel farm must the technician who performs the work. A copy of this farmust 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 Nam: C114f J- ,3p Service Station No.: Site Address: / /. cs ca �� City: /27,0,47"'e—'r" Zip: Facility Contact Person: He4 r r Contact Phone No.: Makdmodel of Monitoring System: Und 71f Date of Testing/Service: I -17-10 B. Inventory of Equipment Tested/Certified t9sEr1c the annronriate boxes to indicate specific equipment insvected/serviced: T ID:_ Tank Gauging Probe: Model: Space or Vault Sensor. Model: 6 ping Strmp/Trench Sensor (s): Model: C3Fdl Sump Sensor (s): Model: C E!yy echanical Line leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Tank OverfflMgh-level Sensor: Model: rlChh r_ Snecifv ern in. tvve and model in Section E on T ID: CA t (Tank Gauging Probe: Model: '0 4ular Space or Vault Sensor Model: tj +,C L F o ping Sump/Trench Sensor (s): Model: ' ❑ll FiSump Sensor (s): Model: &Aechanical Line Leak Detector. Model: � -. ` ' C ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: �aee 2 1710ther. Soecifv eauin. tvoe and model in Section E on Pag 2 T ID: ( e Tank ID: Tank Gauging Probe: Model: [31n -Tank Gauging Probe: Model: uLu Space or Vault Sensor: Model: o ❑Annular Space or Vault Sensor Model: g Sump/Trench Sensor (s): Model: o - 0 ❑Piping Sump/ Trench Sensor (s): Model: ❑ W Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: (gMechanic al Line Leak Detector. Model: 57 -PEO - []Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑OuterS ui . and model in Section E on Page 2 ❑Other, S uip. type and model in Section E on Pa 2 =ensu ID: L Dispenser ID : ;`� - t/ spencer Containment Sensors: Model: .�O tspenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ODivenser Containment Floats and Chains ODi nser Containment Float(s) and Chain(s) ID: Y 1. ' D�j'� nser ID: Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Sheat Valve(s). Containment FI s and Chains ❑ Containment Floats and Chain s Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: _ ❑ Shear Valve(s). ❑ Shear Valve(s). MisImm Containment Float(s) and Chain(s) ElDisoenser 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 equipment. For any equipment capable of generating such reports, I have also attached a co of the ort; (check all that apply): ® System set-up ® b' r port Technician Name (Print): qcr- h Signature: Service Technician No.: 5150yqz Certification No.: Y! 2-L( License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (661) 363-7400 Pace 1 of 3 03/01