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0 MONITORING SYSTEM CERTIFICATION. For Use By All Jurisdictions ltrthin the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Caltfornia 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 mast submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. Generallnfo aliop �� Facility Name:^/i0/JG/d S /%�,sg/ �e'� Service Station No.: Site Address: zemex f' City: Zip: Facility Contact Person:jfn�r/� Contact Phone No.: Make/Model of Monitoring System: lam% 77-,5&-- y Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check the appropriate taxes to indicate specific eouitiment insuected/serviced: Tank ID: Tank ID: On -Tank Gauging Probe: Model: 07,00 % M -Tank Gauging Probe: Model: IA'A mlar Space or Vault Sensor. Model: ^G IFI'Annntar Space or Vault Sensor Model: S Q- ' .2G MPipmg Sump/Trench Sensor (s): Model: 9 %3 a. old +QPfping Sump/Trench Sensor (s): Model: .39c? - GWill Sump Sensor (s): Model: % 3 'd gFill Sump Sensor (s): Model: 9Ffr39ro 2Mechanical Line Leak Detector. Model: 0 ace 0 gMechanical Line Leak Detector. Model: L 2Gt✓0 ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank OverfW/ igh-level Sensor: Model: ❑Tank Overfill/lAgh-level Sensor. Model: ❑Other, Specify and andel in Section E on Page 2 ❑Other, Specify eguip. = and model in Section E on EM 2 Tank ID: Tank ID: QM -Tank Gauging Probe: Model: % ❑In -Tank Gauging Probe: Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor Model: MPtpimg Sump/Trench Sensor (s): Model: O - ' ❑Piping Sump/Trench Sensor (s): Model: afrill Sump Sensor (s): Model: = -939(0 .. []Fill Sump Sensor (s): Model: (AMechanical Line Leak Detector. Model: 1-Q $ c7o0 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/Mgh-level Sensor: Model: ❑Tank Overfill/Mgh-level Sensor- Model: ❑Other- Specify qLwp. and model in Section E on !M 2 ❑Other- Svmffvand model in Section E on Pae 2 Dispenser ID: ;Z. Dispenser ID: @Dispenser Containment ®Dispenser Containment Sensor(s): Model; 8 'Shear Valve(s). , � shear Valve(s). ODispemser Containment Float(s) and Chains) ODispenser Containment Float(s) and Chain(s) Dispenser ID: Dispenser ID: �/ 6 [$Dispenser Contammear Sensors: Model: % [yDispenser Containment Sensor(s): Model:' - fflShear Valve(s). p'Shear Valve(s). ❑D Containment Fl S and Cham(s) DDiTenser Containment Floats and Chain(s) Dispenser ID: - Dispenser ED: TDispenser Containment Sensors: Model: J� lF3 yO-,IO ' Dispenser Containment Sensor(s): Model" 7© @thear Valve(s). l719hear Valve(s). ODiTenser Containment Float(s) and Chain(s) ❑D" nser Containment Float(s) and Chain(s) *Tf 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 equipment. For am equipment capable of generating such reports, [have also attached a cop.v ot'the report; (check aQ that apply): aSystem set-yp l UTA �listory report Technician Name (Print): /j�.�� Signature:L Certification No.: 6Ve - 6 -- Q y License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (916) 927-1557 Pape t of 3 n:mt