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MONITORING SYSTEM CERTIFICATION 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 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: C#Lc94KC`�` L.4 tiC '774, Service Station No.: Site Address: Q00 S, C,N,3Fr? o KCE- GA1�- City: L' . y J / C��, Zip: Facility Contact Person: Contact Phone No.:yZO Make/Model of Monitoring System: r , L r3 A r2C..a C A <- Date of Testing/Service: / p/ Z/ p B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: ; - L,,�� : t7 Tank ID: ct N ❑In -Tank Gauging Probe: Model: []In -Tank Gauging Probe: Model: 0fnnular Space or Vault Sensor•. Model: -I q Y 3-7a -K - e [fnnular Space or Vault Sensor Model: -4 z -e [ping Sump/Trench Sensor (s): Model: -3 q o lRiping Sump/Trench Sensor (s): Model: -p:; / hyo ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: Mechanical Line Leak Detector. Model: .5'T P -M 4 D 20echanical Line Leak Detector. Model: /t; - csss ❑Electronic Line Leak Detector Model: []Electronic Line Leak Detector Madel: ❑Tank OverfiW igh-level Sensor. Model: ❑Tank Overfill/High-level Sensor. Model: ❑Other, S ui . and model in Section E on Pae 2 ❑Other, S ui and model in Section E on Pae 2 Tank ID: 4_t-2 - &' L 4-6, D Tank ID: - P/ C-.5 e Z ❑In -Tank Gauging Probe: Model: 01n -Tank Gauging Probe: Model: Cannular Space or Vault Sensor. Model: S [?Annular Space or Vault Sensor Model: s 4.� PKping Sump/Trench Sensor (s): Model: 7q Mol - ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: 20echanieal Line Leak Detector. Model: 1 J RKAechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: []Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank OverfilU igh-level Sensor: Model: ❑Other, Specify and model in Section E on P e 2 ❑Other, S cft equi and model in Section E on Pae 2 Dispenser ID: s - 'L Dispenser ID: 7 - ❑Dispenser Containment Sensors: Model: ❑D"tspenser Containment Sensor(s): Model: shear Valve(s). ❑ Shear Valve(s). C76jnser Containment Float(s) and Chain(s) ❑Di user Containment Float(s) and Cham(s) --- Dispenser ID: 3 Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: Erthear Valve(s). ❑ Shear Valve(s). 26i user Containment Float(s) and Chain(s) ODiTenser Containment Float(s) and Cham(s) Dispenser ID: 3 - Dispenser m: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: F�!Khear Valve(s). ❑ Shear Valve(s). 05ispenser Containment Float(s) and Chain(s) ODispenser Containment Float(s) and Chmn(s) *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at flus 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 equipment For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): Q System set-up © Alarm historyReport Technician Name (Print): -)LV ; IQ G , G / L!�'cr�2u Signature:Certification No.: No.: License No.: q bio - - Testing Compatry Name: Champion Precision Testing, Inc Phone No.: (916) 927-1557 Papp 1 of :i 03101