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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the ,state of Califarmia 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 Mar --ate certification or report must be prepared nor 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 lnfo ation � Facility Name:f DG F Service Station No.: Site Address: �� _ [,/,t�j (� d City: e Ci i .... ` Q Zip: Facility Contact Person: 0— r14 / e Contact Phone No.: Make/Model of Monitoring System: Q�7 L 0/v.[- Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate sumifc euuioment inspected/serviced: T ID: f T ID: / ank Ganging Probe: Model: - Tank Gauging Probe: Model: AX � Space or Vault Sensor: Sump/Trench Model:raSaogi�zigusump/Trench Space or Vault Sensor Model: 12f_136 Kam ping Sensor (s): Model: G `t a v or✓ Sensor (s): Model: e,d x // yo pfill Sump Sensor (s): Model: ❑ Sump Sensor (s): Model: echanical Line Leak Detector. Model: LiJ 26mbanical Line Leak Detector. Model: Me -,9 ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor. Model: ❑Tank Ovetfill/High-level Sensor: Model: ❑Other, S e ' ui _ and model in Section Eon Pae 2 []Other, S ui a and model in Section E on Page 2 � I f ' Tank ID: FTD: -Tank Gauging Probe: Model: A 6' / Ola -Tank Gauging Probe: Model: rular Space or Vault Sensor: Model: D qs vrr4 []Annular Space or Vault Sensor Model: Pipoing Sump/Trench Sensor (s): Model: &A llqLfaaa ❑Piping Sump/Trench Sensor (s): Model: DEffi Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: [YMechanical Line Leak Detector. Model: ,# Llr_4) ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line leak Detector Model: ❑Tank Overfill,/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, S e and model in Section E on Pa e 2 ❑Other, 9LUOR and model in Sermon E on Page 2 Dispenser ID: % Dispenser ID: Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: Vispenser P& hear Valve(s). L� ear Valve(s). user Containment Float(s) and Cham(s) [ is user Containment Float(s) and Chain(s) Dispenser ID: Dispenser ID: �4 09i'spenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: 11 ighear Valve(s). 5kShear Valve(s). QD' r Containment Float(s) and Chains nser Contaimuent Float(s) and Chain(s) Dispenser ID: q4_10 Dispenser ID:/ L s _ / d ❑Dispenser Containment Sensors: Model: []Dispenser Containment Sensor(s): Model: MShear Valve(s). 0,0ear Vaive(s). Mi nser Containment Float(s) and Chain(s) 90ispenscr 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 - 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 egwipmt For any equip_,m, ecapable of generating such reports, l have also attached a cop of the report; (Check all that apply): l� System set-up IJ AlArm report Technician Name (Print): S_17�6,_rAp_ Signature: Certification No.: St g Lt License No.: Testing Company Name: Champion Precision Testing, Inc ,., ..... Phone No.: (916) 9277-1557 paar. 1 of "i IYiM