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Champion P.O. Box 13059 <br /> Sacramento, CA 95813-3059 <br /> Precision Tank Testing <br /> License No. 73543 CA 800-660-9443 <br /> NEV 800-949-9443 <br /> (916) 927-1557 <br /> Fax: (916) 927-7345 <br /> MONITORING SYSTEM EQUIPAIENT CERTIFICATION <br /> Date of Testinz/Servicing: ! >< / Facility Name: <br /> Site Address: .a-+ C .,` l��'. City:)11`s►.L' �;: <br /> Zip: <br /> Facility Contact Person:64157E ( "~t 1 Contact Phone No.: <br /> r <br /> Make/Model of Monitoring System(s): IF _F��- '��e 7LS Location of Control Panel(s):J�,tl=0�-_ <br /> Make./Model of Line Leak Detector(LLD)�LG�j ;�(, �- LLD Leak Threshold: 71 9-P.M. <br /> Complete the following checklist: <br /> ❑ INo* I Monitoring system is operable per manufacturer's specifications? <br /> ❑ Yes No* Audible alarm is operational? <br /> ❑ Yes No* Visual alarm is operational? <br /> Yes ❑ No* Monitoring system is secured from unauthorized tampering? <br /> ❑ Yes No* For pressurized piping systems, do the turbines automatically shut down if the monitoring system detects a leak, <br /> ❑ N/A fails to operate,or is electrically disconnected? If yes,which monitoring devices initiate positive shut-down? <br /> ❑ Yes No* For monitoring systems which serve as tank overfill warning devices, does the overfill warning function operate <br /> ❑ N/A properly? If so,at what percent of tank capacity does the alarm trigger? % <br /> * In the comments section below,describe how and when these deficiencies will be corrected. <br /> Check the appropriate boxes to indicate specific equipment inspected/serviced: <br /> Tank ID No.: 1 - 0- 2 Tank ID No.: 1„I L Tank ID No.: 5- S-U tii� Tank ID No.: <br /> Annular Space Sensor U Annular Spat Sensor Annular Space Sensor 0 Annular Space Sensor <br /> ❑ Piping Sump Sensor ❑ Piping Sump Sensor Piping Sump Sensor ❑ Piping Sump Sensor <br /> In-Tana Gauging Probe ❑ In-Tank:Gauging Probe In-Tank Gauging Probe ❑ In-Tart Gauging Probe <br /> ❑ Dispenser Containment Sensor(s) ❑ Dispenser Containment Sensor(s) ❑ Dispenser Containment Sensor(s) ❑ Dispenser Containment Sensor(s) <br /> Mechanical Line Leak:Detector ❑ Mechanical Linc Lczk Detector Mecha-niczl Line Leal:Detector ❑ Mechanical Line Leal:Detector <br /> ❑ Electronic Linc Leak Detector ❑ Electronic Line Leak Detector ❑ Elcetr chic Line Leak Detector ❑ Electronic Line Leak:Detector <br /> Comments:StF��p�ci N\1 SSt ►J Et C94>t '9�V SIL S- U UL. /.y),J hiUL.L�+� SCS Q -- <br /> uSQ� �t U'�" At;T1lYs.'T� <br /> I certify that the equipment identified above was inspected/serviced in accordance with manufacturers' guidelines. Attacbed <br /> to this Certification is information (e.g. manufacturer's cbecklists, etc.) necessary to verify that the above information is <br /> correct and to describe any repairs, replacement,or recalibration of equipment. <br /> 'Fame of Qualified Technician(print): I I (?N� l�.hMp3 Si2matl.e:,;�1 �e l �_�S _ • - -c=•:. <br /> Testing Company Name:_fs1..1d�.M ^�Ip►�;: reC7Itj4: , Phone No.: ��6b. 3d, <br /> UN436 <br /> Rev.09/17/97 <br />