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• 0 MONITORING SYSTEM CERTIFICATION For Use By All.furisdtctions Within the Stare of -California iuthorir✓ Cited- Chapter 67, Health and So fe{v Code; Chapter 16, Division 3, 71te 23, CaitJornta Code of ;Red Iations Trus torm must be used to document testing and servicing of monitoring equipment A separate certification or report must be prenared for etch inomforina systetn control ganef by the technician who performs the worlL A copy of flus form must be provided to the tank system owner/operator. The owner/ope:atur must submit a copy of rias form to the local agency regulating UST systems within 30 days of test date. A. General Wormation / Facility Name: (f'A' <z JI -am Service Station No.: Site Address: S'6 k �ltat�i r is �y City: c ilr To.n zip: Facility Contact Person: Contact Phone No.: Make/Model at Monitoring System: T- S' ?So Date of Testing/Service: 9- --0(- B. Inventory of Equipment Tested/Certified VUR] ...r - • Af uud W inusuzmc liC Mt L 111 servWea T ID: Tank Gauging Probe: Made;: AIAP- t Tank Gauge ag Probe: t&Tank Model: ra q - r Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model• O 4 �� d C3 ng SumpiTiendt Sensor (s): Model: y o OPiping Sump/ Tench Sensor (s): Modes []Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑b�2Chanical Line Leak Detector. Model: ❑l�fe�fianirai Line Leak Defector. Model: MEkchumc; Line Leak Detector Model: DElectmnk; Line Leak Detector Model: OTank Overfill/FTigh-level Sensor. Model: ❑Tank Overfil Bigh-level Sensor. Model: ❑Other S and model in Section E on Page 2 {]Other- Specify Top MLe and model in Sem E on P3ge 2 TardID: <EfCL T ID: tTank Ganging Prate: Model:- Tank Gauging Ptobe Model: aun-i tr Space or Vault Sensor. Model: ct D 20 En6muilar Space or Vault Sensor _ldodck ping Sump/1'reach sensor (s): Model: 2 j y 0 20iPing Sump/TrewIt Sensor (s): Model' ORR Samp Sensor (s): Model: CJHU Sump Sensor (s): Model: CINechanical Line Leak Detector. Model:al Line Leak Defector. Model: lectronic Line Luck Detector Model: � Line Leak Detector Model: ❑Tank Ove>fiil/High4crvei Sensor. Model: ❑Tank Overfill1figh-level Sensor. Model: ❑Other. S and model in Section E on Page 2 ❑Other, S fv of ciand model in Section E on P e Dispenser ID: -Z Dispenser ID: ) ❑_D`ispenser Containment Sensors: Model: .74-41 ODispenser Contain neat Sensor(s): Madel- ! Valve(s). L�" Valve(s)- Containment Floats) and Chains) D' r Containment Fioat(s} and Chain(s) Dispenser ID: f A 6 Dispenser ID: '+ ❑Dispenser Containment Sensors: Model: ODispenser Containment Sensor(s): Model: Fillear Valve(s). Ly' bear Valve(s). wtspenser Conraiamem Float(s) and Cham(s2 26ispenser Containment Float(s) and Chains) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ODispenser Canaiamen Sensor(s), Model: ❑ Shear Valve(s). O Shear Vaive(s). OD Containment Float(s) and Cham(s) []DigSnser Conrammem Means) and Chains) 'If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at this facility_ C_ Cer'tifiCatiOR - i certify that the ayuipment identified in this document was inspeaediserviced in accordance with the manufacturers' guidelines. Attached w this Certification is information ALg. manufacturers' checilists) oetxssary m Verify that this information is correct and a Plot Plan showing the Layout of monitoring, equipment For any equipment capable of nnerating inch capons, f Save also attached a coaym a the(_q',uq_ (chea aII rharapply): Q Svstem set-up /�'7�,.�1y} tar ra om report Technic. 'Mame (PZlnt): _ `(/� < (C G�%/1 J Signature: Certification No.: S( 2t( License No.: C S Z GeT Testing Company dame: Champion Precision Testing, Inc Phone No.: (916-192-7-1557