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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited.•Chapter 6.7.Heatth 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 to certification or report must be grepalpd for each monitoring&gem controlpanel by the technician who performs the work- A copy of this form must be provided to the tank system owner/operator. The owner/ for must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information FacilityName: 175' Service Station No.: Site Address: _7 �L2_ -L M City. rro-C k 7-4,A Zip: Facility Contact Person: Contact Phone No.: Make/model of Monitoring System: Uc-edez TLx-9 S6 Date of Testing/Service: B. Inventory of Equipment Tested/Certified Cheek, the appropriate boxes to indicate!gggEc Np:jpment in iced: TID: j 72 Tayk ID: 12 Tank Ganging Probe: Model: &A&'owj Tank Gauging Probe: Model: 5- 5nular Space or Vault Sensor. Model: )jmular Space or Vault Sensor Model:ing Sump/Trench Sensor(s): Model: I o 7710rid -2,12 Wiping Sump/Trench Sensor(s): Model: o OF411 Sump Sensor(s): Model: EIY.M, Sump Sensor(s): Model: �Lech;nical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: ElElecizonic Line Leak Detector Model: OEIeWouic Line Leak Detector Model: OTank Overfill/High-level Sensor Model: OTank Overfillffligh level Sensor Model: �§�er,Sp2g!fy equip.type and model in Section E on Page 2 EdOther,§ME&eqUIP %M and model in Section E on Page 2 T ID: se 6- Tank ID: -Tank dauging Probe: Model: Mftr- I 01n-Tank Gauging Probe: Model: t -Aximular Space or Vault Sensor: Model: Q .UHCl _ (_3 OAnnular Space or Vault Sensor Model: U(Pi-ping Sump/Trench Sensor(s): Model: 1')2 C/q 'k -)jo- ®Piping Sump/Trench Sensor(s): Model: OPSump Sensor(s): Model: OFill Sump Sensor(s): Model: hanical Lim Leak Detector. Model: J16-oft OMechanical Line Leak Detector. Model: OElectronic Line Leak Detector Model: OElectronic Line Leak Detector Model: OTank Over6ll4ligh-level Sensor. Model: OTank Oveffillffligh-level Sensor Model: CLOLhM,SRE&2juj.DE and model in Section E on Pae 2 1 0 eqqip. and model in Section E on Page 2 Dispenser ID: 14. 4- Dispenser ID: []Dispenser Containment Sensors: Model: DDispenser Containment Sensor(s): Model: 2_o ff 0 Shear Valve(s). 0 Shear Valve(s). Opis jnnser Containment Float s)and s ODispenser Containment Float(s)and Chain(s) Dispenser ID: 6 Dispenser ID: e'-& ODispenser Containment Sensors: Model: 2OS' ODispenser Containment Sensor(s): Model: : ok 0 Shear Valve(s). 0 Shear Valve(s). 0 Containment P2!!Qs and.Chain(s) ODispenser Containment fl2Ws and Chain(s) Dispenser ID: Cf*//-) Dispenser ID: 11 ,1- (2- 013ispenser Containment Sensors: Model: ODispenser Containment Sensor(s): Model: 20(r 0 Shear Valve(s). 0 Shear Valve(s). ODiVenser Containment Float(s)and Chain s) ODispenser Containment Floats)and Chain -If the facility 0011W=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 ins serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information(&g manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipmgW'For any equipmevVcapable of generating such reports,I have also attached a copy of the report;6k*gz*all tkar apply): CY-System set-up arm 'st report Technician Name(Print): Tee,- rpj,j7 Signature: Certification No.: License No.: Testing Company Name: Champion Precision Testing,Inc Phone No.: (916)927-1557 %we.I nf.3 nzmt