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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 works 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: 1& a c r ar77j—, , Service Station No.: r Site Address: `290 . lql i? t ly S,`T— city l li'�s' �� Zip: Facility Contact Person: ed C G' � . 0 ;z C( Contact Phone No.: Make/ModeI of Monitoring System: s- Date of Testing/Service: 3 - Z9 -6r, B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate gLe#ic Wipment in serviced: Tank ID: Tank Gauging Probe: Model: - 1 Tank ID: iG-Tank Gauging Probe: Model: PI,4y"= 1 �u1ar Space or Vault Sensor. Model: o -- o 06armlar Space or Vault Sensor Model: O 7l q j Yd w c{ 0 ping SumplTrench Sensor (s): Model. o .. pin Sum /Trench Sensor (s): g P ()0:7,9(q'Z Model f ? fr OFj Sump Sensor (s): Model: 01 j� Sump Sensor (s): Model: � edhanical Line Leak Detector. Model: G 9FAechanical Line Leak Detector. Model: Ke 5rj? A?<a OElectronic Line Leak Detector Model: OElectronic Line Leak .Detector Model: OTank OvetfillMgh-level Sensor. Model: OTank Overfill/High-level Seng- Model: pother, S ui . and model in Section E on Page 2 OOther, S and model in Section E on Page 2 Tat* ID: Q i e fd (_ Tank ID: pTn-Tank Gauging Probe: Model: MAt ❑In -Tank Gauging Probe: Model: Space or Vault Sensor. Model: 4 ..-. � 2c kp_ng OAmmlar Space or Vault Sensor Model: Sump/Trench Sensor (s): Model: e7 2,j (i7ja -2-0 OPiping Sump/Trench Sensor (s): Model: OFSump Sensor (s): Model: OFill Sump Sensor (s): Model: O hanical Line Leak Detector. Model: OMechanicai Line Leak Detector. Model OElectronic Line Leak Detector Model: OElectronic Line Leak Detector Model: OTank Overfill/ ligh-level Sensor Model: OTank OverAWHigh-level Sensor: Model: 00ther, S and model in Section E on Pa 2 pother, S ui . and model in Section E on Page 2 FID: Fuse DiRenser ID: 3-0- C l ispenser Containment Sensor(s): Model: ear 9 Shear Valve(s). ODispenser Containment Float(s) and Chains) ODispenser Containment Float(s) and Chains) Dippenser II): ' ��' G =rw ID: ;•�rMbispenser Containment Sensors: Model:Containment Sensor(s): Model: shear Valve(s). dShear Valve(s). 011ismuser Containment Floats) and Chains O r Containment Fioat(s and Cham(s) D" nser ID: � to ispeuser Containment Sensors: Model: r ID: ser Containment Sensor(s): FShear Model: Shear Valve(s). Valve(s). ODispenser Containment float(s) and Chain(s) ODispenser Containment Float(s) 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.g. manufacturers' checkEAJ cessary to verify that this information is correct and a Plot Pian showing the layout of monitoring equipment- For any equipable of generating such reports, I have also attached a copy of a report; (check all that apply): System set-up ' Oty report Technician Name (Print): LTJ S i P a ,r 4,1 ` Signature: Certification No.: f 2-t( License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (916) 927-1557 Pane 1 of:i lZ3mr