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• • MONITORING SYSTEM CERTIFICATION For (Ise 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 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. General Information Facility Name: �/�.+ j2�' 3A I % V r� Service Station No.: Site Address: SQ & W C k(R/C rte 4 r,r City: a S"tic FrT.. Zip: Facility Contact Person: Sc 2! C r l c{ Q r Sl 017-H i -H Contact Phone No.: d Make/Model of Monitoring System: TLS 3S U Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check the a2propriate boxes to indicate specific equipment ins serviced: T ID: ID: ' auk Ganging Probe: Space or Vault Sensor: Model: �+ �-( Model: o yZb ankGauging Probe: FT mular Space or Vault Sensor Model: to -Annular Model: X61 •- �j diping Sump/Treuch Sensor (s): Model: 0'7 )4i 'ld•-ZG Mping Sumpfrrench Sensor (s): Model: s • d- d ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Ucchanical Line Leak Detector. Model: ❑IvJechanical Line Leak Detector. Model: (�lectranic Line Leak Detector Model: p6c lectmnic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor. Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, S and model in Section E on Pa 2 ❑Other, S td . and model in Section E on Pae 2 T D' Tank ID: Tank Gauging Pmbe: Model: ❑ht -Tank Gauging Probe: Model: Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor Model: �� C9P-ping Sump/Trench Sensor (s): Model: ❑Piping Sumpfrrench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑i ftchanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: lectromc Line Leak Detector Model: ❑Electronic Line Leak Detector Model: []Tank Overfill/High-level Sensor: Model: []Tank Overfill/FTgh-level Sensor: Model: ❑Other, S and model in Section E on Pae 2 ❑Other, S and model in Section E on e 2 Dispenser ID: i 4 Z Dispenser ID: -7 ❑D' Containment Sensors: h Valve(s). Model: ❑Dis nser Containment Sensor(s): p ear Valve(s). Model: p8fTenser Containment Float(s) and Chains is nser Containment Float(s) and Chain(s Dispenser ID: Dispenser ID: 9 ❑Dispenser Containment Sensors: Model: []Dispenser Containment Sensor(s): Model: t-ghear Valve(s). albear Valve(s). 211ia= Containment Float(s) and Chains) 216ispenser Containment Float(s) and Chains) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ODigEmer Containment Float(s) and Chain(s) ODispenser Containment Float(s) and Chains) *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 equipme For any equip"'50�� capable of generating such reports, I have also attached a co v of the re or ; (check all that apply): m set -u ',9 ¢port Technician Name (Print): L2�( S Signature: Certification No.: 5-12-1 License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (916) 927-1557 PROP 1 of 3 n3/M