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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 sesaarate 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 ownerloperator. The ownerfoperator 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: Service Station No.: Site s: Citi': Ay ��7— LID: .34� Facility Contact Person: Contact Phone No.: 1951,�� MakaModel of Monitoring System: ' ,�� .G �i S Date of Testrng(Service/��,5 B. Inventory of Equipment T Certified Check the MMriate bones to' c e d• Tank ID: Alt,% Tank ID: Mf�-Tank Gauging Probe: MM-Tank Gauging Probe: UlAmmlar Space or Vault Sensor: 11 l3Anmdar Space or Vaunt Sensor 9r Wiping Sumprrmnch Sensor(s): a ing S rench (s): ❑Fill Sump Sensor(s): is ❑Fill Sump Sensor(s): Model: EMechanical Line Leak Detector. Model: 2114=hanical Line Leak Detector. Model: OEICCUIDRiC Lame Leak Detector Model: 00ectronic Line Leak Detector Model: ❑Tank 0vedMMgh4evd Sensor. Model: ❑Tank Ove 'gh-level Sensor. Model: 00ther.§gSE& and modelin Section E on Page 2 ®Other: S and model in Section E on P e 2 Tank ID: Tank ID: (3116-Tank Ganging Model: ❑In-Tank Gauging Probe: 9?AnmAw Space or Vault l: ❑Annular Space or Vault Sensor Model: Piping S tT (s): Model r7iping Sumpfrrench Sensor(s): Model: OFill Sump Sensor(s): ❑Fill Sump Sensor(s): Model; Line Leak OMechamcal Line Leak Detector. Model: ❑Electronic Line Leak Detector ❑Electronic Lane Leak DeWctor Model: ❑Tank Overfilll&iglt level Sensor. ❑Tank OverfillJHigh-level Sensor. Model: ❑Otl<er;S and model in Section E on e 2 ❑Other,S and in Section E on P 2 Dispenser ID: Dispenser ID: --� Containment Sensors: Model:�V4 Wispenser Containment Sensor(s): l c� grghcar Valve(s). Z,Sheaa Valve(s). Containment Float(s)and Chains) ODispen=Containnu=Float(s)and Chains) Dispenser 1D: Dispenser ID: a6ispenser CSensors: Model:,,, t,2 p ' ❑Dispenser Containment Sensor(s): Model: [Khear Valve(s). ❑ Shear Valve(s). OD!§=Containment Floats)and Chain(s) ODispenser Containment Float(s)and Chain(s) Dispenser ID: Dispensa ID: @Vispenser ContainmentSensors: Model: 7Y ODispensa Containment Sensor(s): Model.: tlhear Valve(s). ❑ Shear Valve(s). ODispenser ContammW Float(s)and Chains) ❑D' r Containment Floats)and Cbain(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 equipm t capable of generating such reports,I have also attached a copy 'the rt; lcheck all that appt}+): F 'Srystcna -upZhistory report Technician Name(Print): Signature: _ Certification No.: ® _ f — Lace nse No.: _ Testing Company Name: Champion-recision Testing; Inc Phone No.: (9I6) 927-155? Pacse 1 of 3 te3ln�