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MONITOFAG SYSTEM CERT MICA*ON For Use By A 11.1urisdictions Within the State of California Authority Cited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3. Title 23, California.Code of RoregulravA—m-gaabe tions This form must be used to document testing and servicing of monitoring equipment. A — systcm control nanel by the technician who performs the work. A copy of this form must be provided RMW9d h i must submit a copy of this form to the local agency regulating UST systemsto the tank system-owner/operator. The ownertoperatOr within 30 days of test date. A. General Information Service Station No.: Facility Name: Site Address: City: 1 c zip: Facility Contact Person: Contact Phone No.: MakdModel of Monitoring System: Date of Testing/Service: B. Inventory of Equipment Tested/Certified Cheek the WyMrlaft boxes to mdicxte sperAIns lected/ mced: .9 meat se MirTank ID: T*ID: Model: 131n-Tank Gauging Probe: Model: 1,01 OIn-Tank Gauging Probe: ErAjimilar Space or Vault Sensor. Model: f - t s OAmmIar Spam or Vault Sensor Model: EZIPiping SumpfrrenCh Sensor(s): Model: -Z22,,# '_A L []Piping Sump/Trench Sensor(s): Model: 77/' L []rill Sump Sensor(s): Model: OFiU Sump Sensor(s): Model: (Mechanical Line Leak Detector. Model: I—r) �0 L!0 OMechanical Line Leak Detector. Model: I-.0 1 E3]Blectronic Line Leak Detector Model: []Electronic Line Leak Detector Model: OTank OverffiWigh-level Sensor: Model: OTank Over flUAffigh4evel Sensor: Model: [30tber,Sand model in Section E on Page 2 []Other,SRSEft M!2. =and model in Section E on Page 2 Tank ED: P, iTank ID: - 6n-Tank Gauging Probe: Model: 5 ir Z& Oln-Tank Gauging Probe: Model: 13AnnWar Space or Vault Sensor. Model: T �-P []Annular Space or Vault Sensor Model: (Piping SumpjTren6 Sensor(s): Model: C.-.S OPiping Sump/Trench Sensor(s): Model: OFiU Sump Sensor(s): Model: OFill Sump Sensor(s): Model: &&cjjamal Line Leak Detector. model: TIrp-rht_12- �OMochanical Line Leak Detector. Model: OMectronic Line Leak Detector Model: OElectronic Line Leak Detector Model: []Tank Overfflifiligh4evel Sensor: Model: OTank OverfilMgh-level Sensor: Model: 00ther,Specify Lc&. M and model in Section E on Page 2 []Other, Specif in and model in Section E on Pa 2 Dispenser ID: Dispenser ID-. ODispenser Containment Sensors: Model: j tj 1),41 ODispenser Containment Sensor(s): Model: '4 0 Shear Vahre(s). 0 Shear Valve(s). ODispenser Containment F12!gg and Chains ODi!Mnser Containment Float(s)and Chain(s) Dispenser ID: Dispenser TD: ;7— IW' I ODispenser Containment Sensors: Model: I-)fi(5 ODispenser Containment Sensor(s): Model: 0 Shear Vah*s). 0 Shear Valve(s). (3Dispenser Cmtainment FIs)and C!!!!n s) ODispenser Containment E2!As2 and gEjn sj Dispense:•ID: Dispenser ID: ODispenser Containment Sensors: Model: []Dispenser Containment Sensor(s): Model: 0 Shear Valve(s). 0 Shear Valve(s). QDiqpenser Containment Float s)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(e.& 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 aco of the revort; (check aU that apply): 13 system wt-up U hf�g�ort Technician Name(Print): T70 57-2� r- hS Signature: Service Technician No.: U YCR Z Certification No.: License No.: Testing Company Nam: Champion Precision Testing, Inc Phone No.: (661) 363-7400 Page I of 3 03/01