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Champion FILM ��� O. Box 13059 <br /> `"1Sacramento, CA 95813-3059 <br /> Precision Tank Testing CA 800660-9443 <br /> L,ce^se �o. /3S-;S 9 a j NEV 800-949-9443 <br /> C <br /> J; (916) 927-1557 <br /> Fax: (916) 927-7345 <br /> iMOMTORI G SY STEi-VZ EOUZPINZENT CERTIFICATION <br /> Date of Testing//Servicina: ) ) /_/0 /AA Fzciliy Nam, t: � p I� -�u iT!I- I y�y� ( C>i_ <br /> Site Address:l u u g NOR-- t! r Q)N1 t_ DR' City: S)I-Odcm *{ — Zip: <br /> Fzcilit) Conuct Person: Z`n S 4r11T Contact Phone No.: <br /> `'zke;l lodel of.Monitoring S;stem(s):';WWT�( '(� t r.Q rr C7 7Z Location of Cort:of Panel(s): <br /> e!Mlode1 of Line Leak Detector(LLD)�r,�•Zk" LLD Lcak i li esheld: (,`,t a -2 ?.M. <br /> Complete the following checklist: <br /> Yes ❑ No` 1✓0nitoring system is operable per mnzs.,-f_c-:rer's specificztionS? — <br /> Yes ❑ No` Audible alarm is operational? -- <br /> Yes ❑ No` Visual alarm is opemiional? <br /> Yes ❑ '.To` ( Monitoring system is secured tzsnpeang? i <br /> ❑ Yes ❑ No` For pressurized pipings)-sums, do the ru-bi;tes automatically shut down if the monitorm system detects a leJ:, <br /> C2 J/,q fails to operate,or is elecn-icaily discorm:cud? Ifyes,\+-hich monitoring devices initiate positive shut-do�s;t? i <br /> ❑ Yes ❑ No For monitoring systems x hick serve 2.s t:---k overfill warning devices, does the overfill warning;tinction oiler ase <br /> I <br /> ❑ N/A properly? if so,at •hat percent of tank capaciy does the alarm trigger? % <br /> In the comments section below,describe how and when hese deficiencies-will be corrected. <br /> Check the appropriate boxes to indicate specific equipment ins pecieWsen-iced: <br /> Tank ID No.: I. n- 1 Tank 1D No.:'_ -U�,%Lr _ I Tank ID No.: I Tank iD No.: --- -- , <br /> Annular Spzcc Sensor Annular Spz:e Sensor D Annular Spzcc S:nsor Q Annular Space Sensor <br /> Piping Sump Sensor Piping Sump Sensor ❑ Piping Sum?Sensor ❑ Piping Sump Sensor <br /> In-TL�I.Gauging Probe In-TLak Gzaging Probe 13In-T2*% Gzucing Probe ❑ Ir.-TL%k Gauging Probe <br /> Disperse Containment Sensors) Disperser Containment Scnsor;s) ❑ Dispenser Contvnrnent Sensorts) ❑ Dispenser Conainment Scnsor(s) <br /> Mechanical Linc Lezk Detector IV McchaniczJ Line Leak Detecior ❑ Meehznical Line Leak Detector ❑ 1,!cchznical Line Lcak Detretor <br /> ❑ Electronic Line Leak:Dnzmr ❑ Electronic Line Lezk Detector ❑ Eleeu-onie Line Lcak Detnetor ❑ Electonie Linc Leak D:tcetor <br /> Comments:T_AJ„ � �_ j�r /��Q t�FS <br /> I certify that the equipment identified above µ-as inspected/sen'iced in accordance with m2nuf2cturers' guidelines. .4tt2ched <br /> to this Certification is information (e.g. manufacturer's checklists, etc.) necessary to verify that the above information is <br /> correct 2nd to describe any repairs, repl2cement, or recalibration of equipment_ <br /> Name of Qualified Technician(pant):LAJ 1)I !tz k% UW 3 5L,4. Sigrarwt:` Ll� <br /> r <br /> Testing Company Name: Phone No.: (liD0_} ✓v u -��--��_ <br /> LN--036 <br /> Rev.0911757 <br />