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M©NT*RING SYSTEM CERTIFPATION [,'or Use By All Jurisdictions Within the State of California Iuthority 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 se arate-ce go - ust be prepared for each monitoring system control panel by the technician who performs the work. Acopy ct!' s,tltn �Clf�i; vided 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_ JAPE 1 4 ZG08 A. General Information Facility Name: ff�t rt7' IZ e t° Rt, C' Service Station NoINMIR ON � H . ,!� PERN11 EW L15 Site Address: S-Z) '�T c'/t.4 r? 1 z4`r( City: C,a,, Zip: Facility Contact Person: Contact Phone No.: 7 c - Y z'z - /?3 Y Make/Model of Monitoring System: V '5 ;c Date of Testing/Service: /f Sr/o 1 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate MLeffic guipment ins ted/serviced: Tank ID: l - F-7 Tank ID: g'r`n-Tank Gauging Probe: Model: ,C - ©f-Tank Gauging Probe: Model: (,¢ - LAnnular Space or Vault Sensor' Model. Ic)—<ez-e CT�nular Space or Vault Sensor Model: EJ11 ping Sump/Trench Sensor(s): Model. 7f,r-3jn -7-i 011-ping Sump/Trench Sensor(s): Model:--ryy -o - ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: 2Erectronic Line Leak Detector Model: S7Y�Y S cr 's E%Iectronic Line Leak Detector Model: ❑Tank OverfilUHigh-level Sensor: Model: ❑Tank OverfilMgh-Ievel Sensor: Model: ❑Other, Specify and model in Section E on PaLe 2 ❑Other, Sec' a and model in Section F on Page 2 Tank ID: - t. Tank ID: -Tank Gauging Probe: Model: ,e-<e,;'c-;- ❑ln-Tank Gauging Probe: Model: pknnular Space or Vault Sensor: Model: 7 7y-3,-ro E]Annular Space or Vault Sensor Model.- 2f liping odel:ping Sump/Trench Sensor(s): Model: ❑Piping Sump/Trench Sensor(s): Model.- ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model- ❑Mechanical Line Leak Detector. Model: []Mechanical Line Leak Detector. Model: 051-ectronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank OverlilMgh-ieveI Sensor: Model: OTank OverfillI igh-level Sensor: Model: ❑Other, Spec' ui . and model in Section E on PaLe 2 ❑tither, S at- DE and model in Section E on Pa e 2 Dispenser ID: _ / - Z Dispenser ID: -7-- ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s).- Model: ET-&hear Valve(s). 3-Shear Valve(s). __1�Yispenser Containment Float(s) and Chain s) gTinser Containment Floats and Chain(s) D ispenser ID: - Dispenser ID: ispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: heaValve(s). ElShear Valve(s). nser Containment Floats)and Chain(s) ❑Di r Containment Float(s)and Chain(s) Dispenser ID: 5—K, Dispenser 1D: ❑Dispenser Containment Sensors. Model: ❑Dispenser Containment Sensor(s)-. Model: 5-Shear Valve(s). ❑ Shear Valve(s). O"i user Containment Float(s)and.Chain(s) 0DiR2nser 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 - t certify that the equipment identified in this document was inspected/ser-Oced 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 Flan showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also attached a copy of the report; (check all that apply): urg_ystem set-up �ar�thisto i)Ort Technician Name(Print): Signature. - -- -- Service Technician No.: c 71f f Y Certification No.: A ;1 7 X 1�-5 License No.: Testing Company Name: Champion Precision Testing, Inc Phone No, (661) 363-7400 Pane I of 3 03101