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MONITGRING SYSTEM CERTIFIATION For Use ByA11.1urisdictions Within the State.nfCalijornia Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California Code o)Regulation 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 Infori ation Service Station No.: Facility Name: i Site Address: .Z%2 d fel G e l 4,�� City: T r c(� zip: Facility Contact Person: /T ir4 f A/r'1 Contact Phone No.: ",� 3 Make/Model Of Monitoring System: /`i,-nr / jt!�I Date of Testing/Service: Q= B. Inventory of Equipment Tested/Certiried Check the ro riate buses to indicate Mccific equipment' eeted/serviced: Tank ID: tr�e Tank ID: 21a-Tank Gauging Probe: Model: •G M-Tank Gauging Probe: Model: - ular Space or Vault Sensor. Model: 4L 39i� QAnrmlar Space or Vault Sensor Model: [$Pip ng SumptTrench Sensor(s): Model: 5°S/3.f Z1 d fi&�tping Sump/Trench Sensor(s): Model �2Q5 tz❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Madel: ❑Mechanical Line Leak Detector. Model: <O,2d ' ❑Mechanical'Line Leak Detector. Model: j LAS ❑Elecubiiic Line Leak Detector Model: QEltxtronic Line Leak Detector Model: ❑Tante Overfill/liigh-level Sensor: Model: (]Tank Overfill4ligh-level Sensor: Madel: ❑Other,S ui . and model in Section E an Page Z QOther S . type and model in Section E on Pae 2 FFC]FFill : Tank ID: nk Gauging Probe: Model: � c-? Ola-Tank Gauging Probe: Model: lar Space or Vault Sensor: Model: 7 y3 d� Q� Space or Vault Sensor Model: Stffi /Trench Sensor(s): Model: �' ❑piping Sump/Trench Sensor(s): Model: g P ( ) Model: ump Sensor(s): Model: ❑Fill Sump Sensor(s):anical Line Leak Detector. Model: C n 2a d QMec IIe TJeor.Leak Detector Modelronic Line Leak Detector Model: ❑Tank Overfill/ igh-level Sensor: Model: ❑Tank OverfilMgh-level Sensor: Model: ❑Other,S city ui and model in Section E on Pae 2 ❑Other,Snecift couno. and model in Section E on Pa e 2 Dispenser ID: -;z_ Dispenser ID: /. ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: U/Se s . Gg Shear Valve(s). Obi user Containment Float(s)and Chain(s) s eraser Containment Float(s)and Chain(s) Obi Dispenser ID: a Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ©'hear Valve(s). ❑ Shear Valve(s). r Containment Floats)and Chains) ❑D" Containment Floats)and Chain(s) Dispenser ID: �, Dispenser ID: ❑Di []Dispenser Containment Sensors: Model: spenser Containment Sensor(s): Model: O-Shear Valve(s). ❑ Shear Valve(s). pDi eraser Containment Float(s)and Chains) OD i user Containment Float(s)and Chain s) *lf 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.Certifintipe is information (e.g. manufacturers' checklists) necessary to verify that this information epreports, is correct and n Plot Plan.showing the layout of monitoring equipment F�u �ipment apahist ry eport le of g such reports,I have also attached a copy of the report:.(check aQ that apply): ®'$ystetm s Technician Name(Print): Keith Huston _ _ Signature: Service Technician No.: L!r l ? 0 U Lt License No.: Certification No.: �o> —� � 7 phone No.: (661)363-7400 Testing Company Name: _Champion Precision Testing, hoc 03101 Page t of 3