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MONITOKING SYSTEM CERTIFICA 'ION For Use By All.Jurisdictions Within the State of California 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 2qparate certification or mpQrt must be otWared for each monitoring system control panel by the technician who performs the worts. A copy of this form must be provided to the tank system ownerloperator. The owner/operator must submit a cagy of this form to the local agency regulating UST systems within 30 days of test dace• A. General Information Facility Name: '- i I e "1 Service Station No.: Site Address: 7 LQ C i.,/ Lk / n ✓ 19 J __ City. L.yc ., i — Zip: Facility Contact Person: Contact Phone No.: MakeJModel of Monitoring System: cif k/ _aTo �i e k Daze of Testing/Service: 5 i 4r B. Inventory of Equipment Tested/Certified Check the xppropriate boxes to indicate specific egEipment' serviced: Talc ID: 1 1 f- Tank ID: Qfn Tank Gauging Probe: Model: C' �. 7 Z ❑In-Tattle Gauging Probe: Model: Minnular Space or Vault Sensor: Model: .� . , ❑Annular Space or Vault Sensor Model. ging Sump/Trench Sensor(s): Model: 4(o 5Q, c ❑Piping Sump/Trench Sensor(s) Model ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank OverfllMigh-level Sensor: Model: ❑Tank Overf l/Mgh-level Sensor: Model: ❑Other, Specify equip. type and model in Section E on Page 2 ❑Other, S and model in Section E on Page 2 Tank ID: Tank ID: _ [31n-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: ❑Annular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: OPipinig SumpiTrench Sensor(s): Model: ❑Piping Sump/Trench Sensor(s)• Model: ❑Fill Smmp Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Mechanical line Leak Detector. Model: ❑Mechanical line Leak Detector, Model: ©Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank OverfilMgh-level Sensor: Model: ❑Tank OverfilMgh-level Sensor: Model: ❑Other, 5 and model in Section E on Page 2 ❑Other, Specify equip. and model in Section E on Page 2 Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Contaituncut Floats and Chain(s) ❑Di nser Containment Float(sl and Chain(s) Dispenser ID: Dispenser ID: ❑Dispenser Containm in Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s), p Shear Valve(s). ClDispenser Containment Float(s)and Chains ❑Eh Conta,nment Fioa s and Cham(s) Dispenser ID: Dispenser ID: ❑Dispm=Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear valve(s). CjDj3MM Containment Float(s)and Chains ODispenser Containment Float(s)and Chain(s) *If the facility contains more tanks or dispensers,copy this form. Include information for eve tank di every and Spenser 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 Certifiotion 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 any equipment capable of generating such reports.I have also attached a co of the re ori; (cfteek a!!tikes apply): C, system set-up © h ort Technician Name(Print): e r Signature: Service Technician No.: j C3 `(Cj .Z Certification No.: License No.: _ Testing Company Name: Champion Precision Testing, Inc Phone No.: 661) 363-7400 Pace 1 of 3 o3nst