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MONITORING SYSTEM CERTIFICA1ION For Use By All.furisdictions Within the Stare of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations (itis form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be yreoarsd for each monitoring system control pane( by the technician who performs the work. A copy of this form must be provided sytem owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems D the tanks within 30 days of test date. A. General Information Service Station No.: Facility Name: Site Address: ci �`( E10(r'�zr iPP City: Zip: Facility Contact Person: Contact Phone No.: 261� q Z f - 2 7 LZ MakeJModel of Monitoring System: l h cc C r*'t C _ Date of Testing/Service: r/-/ 7 -0 '> B. Inventory of Equipment Tested/Certified Check the wollinate bow to indicate ific a ai ment ' serviced: T ID: f n 1 Tank ID: 2 - � Tank Ganging Probe: Model: ❑In-Tank Gauging Probe: Model Annular Space or Vault Sensor: Model: Yi` `l0 ❑Annular Space or Vault Sensor Model: c ppiping Sump/Trench Sensor(s): Model: t qp . ❑Piping Sump/Trench Sensor (s): Madel: X75 V 3 iC �" ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: QMechanical Line Leak Detector. Model L - 000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank oveifi11/fligh-level Sensor: Model ❑Tank Overfill/High-level Sensor: Model: pother, Specitr gpe and model in Section E on Pae 2 1 ❑Other, S and model in Section E on Pae 2 Tank ID: Tank ID: EP ' Tank Gauging probe: Model: 114f - 1 ❑In-Tank Gauging Probe: Model: ©Aj'- rlar Space or Vault Sensor: Model: ✓?°;moi l`io -'126 ❑Annular Space or Vault Sensor Model: opiping Sump/Trench Sensor(s): Model: - ` t `1<% lod ❑Piping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: [2Mwhanical Line Leak Detector. Model: (-0 20c%(- ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Irak Detector Model: ❑Tank Overfill/I igh-level Sensor: Model: ❑Tank Overfill/lAigh-level Sensor: Model: DOS gpecify equip, tyW and model in Section E on Pae 2 ❑Other, Specify equipand model in Section E on Page 2 D' ID: Dispenser ID: Spenser Containment Sensors: Model; i' �U Eabispeuser Containment Sensor(s): Model: _7 cl Shear Valve(s). p"Shear Valve(s). ❑Di Containment Floats and Chains ❑Di nser Containment Floats and Chain s) pispenser ID: Dispenser ID: tspenser Containment Sensors: Model: "' 7 % 36spenser Comainmem Sensor(s): Model: � dSbm Valve(s). C3/Shear Valve(s). Containment Fl s)and Chain s) ❑Di Containment Floc s and Chain s Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ClDispenser Containment Floats) and Chain(s) ODispenser Containment Floats 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(mg. manufacture"' checklists)necessary to verity that this Information is correct and a Plot Plan showing the layout of monitoring equi7Snt. For any equipmfnt capable of generating such reports,I have also attached a copy of thereort; (check all than apply): System set-up h' ort Technician Name (Print): e r h S Signature: Service Technician No.: S O Y CtZ Certification No.: 5 ( Z 4 License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (661) 363-7400 QVnr Psee I of 3