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MONITOCG SYSTEM CERTIFICCON For Use ByA11.1urisdietions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chkpter 16, Division 3, Title 23, California 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 must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: D<'.t 2' (`a ✓ C� Service Station No.: Site Address: `', K (� ,7 int 14 FL Aja D City= S j t c k & A Zip: Facility Contact Person: r vl e c' Contact Phone No.: Make/Model of Monitoring System: . ( re r t� p (Ce _ Date of Testing/Service: 9 _ 5 O B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspectedfserviced: T ID: 5f7 T ID: Tank Gauging Probe: Model:`g t _y_( Tank Gauging Probe: Model ✓1 - Space or Vault Sensor: Model: 62q <,3 ro - 4a Annular Space or Vault Sensor Model: �A,(nnular &APing Sump/Trench Sensor (s): Model: r 4 o 2u EPiping SumplTrench Sensor (s): Model G ❑F' l Sump Sensor (s): Model: ❑ ill Sump Sensor (s): Model: loMechanicai Line Leak Detector. Model: ErMechanical Line Leak Detector. Model t_ ❑Elearonic Litre Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/Mgh-levet Sensor: Model: ❑Other, Specify equip,and model in Section E on Pae 2 ❑Other, S ui . and model in Section E on e 2 T ID: cS! L Tank ID: T= Tanis Ganging Probe: Model f — t ❑In -Tank Gauging Probe: Model: Space or Vault Sensor: Model: 0 Y V ' O 4' 0 ❑Annular Space or Vault Sensor Model: Piping Sump/Trench Sensor (s): Model (y?7 {3Y0 - U ❑Piping Sump/Trench Sensor (s): Model: ill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: Mechanical Line Leak Detector. Model T Yl L 0-I ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank OverfilMgh-level Sensor: Model: ❑Other 5 eq!!!p. DZ and model in Section E on Pae 2 ❑Other, S if ! i2. type and model in Section E on Pae 2 Dispenser ID: Dispenser ID: ' �'- `( ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s). Model: hear Valve(s). n/Shear Valve(s). �6iaxnscr Containment Float(s) and Cltain(s ffbis nser Containment Float(s) and Chain(s) Dispenser ID: 5 G Dispenser ID: .7-0- r ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: GKShear Valve(s). (]Shear Valve(s). UrDispenser Containment Float(s) and Chamjs ONspenser Containment Floats and Chain s) Dispenser ID: '! f - IC)_ Dispenser ID: ire ca h ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: 9Shear Valve(s). C* hear Valve(s). EG1 G user Containment Float(s) and Chain(s) i nser Containment Floa[(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 - 1 certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.p� manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equip�me�°� For any equipmmee t capable of generating such reports, I have also attached a copy of the report; (check all that apply): 'lJ System get-up1.8J1 h' report Technician Name (Print): Signature: o Service Technician No.; Certification No.: (L <( -- - -- License No.. Testing Company Name: Champion Precision Testing, lncPhone No.: (661) 363-7400 Page I of 3 n3/m