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C E', 10 s Qor IO FR� se By All Jurisdictions.! thin the Staf�of Call o is s Authority Cited.• Chapter 6.7, Health and Safety Code;Chapter 16, Division 3, Title 23, California C t`if 14, This form must be used to document testing and servicing of monitoring equipment. 'A separate certification or prepared for each monitoring system control panel by the technician.who performs the work. A copy cf iiti, 'd'd to the tank-system owner/operator. The owner/operator must submit a copy of this form to the local agency _ ems within 30 days of test date. A. General Info rmatio ,a Facility Name: Service Station No.: Site Address: City: Zip: ' - Facility Contact Person: Contact Phone No., Make/Model of Monitoring System: Date of Testing/Service: .- ,B. Inventory of Equipment Tested/Certified Check the gpniErvAe bo:ces to indicate Weak a meat ins 3ected/serviced: Tank ID: Tank ID: OIn-Tank Gauging Probe: Model: OIn-Tank Gauging Probe: Model: 1WAnnular Space or Vault.Sensor. Model: OAnmdar Space or Vault Sensor Model: OPiping Sump/Trench Sensor(s): Model: OPiping Sump/Trench Sensor(s): Model: OFill Sump Sensor(s): Model: OFill Sump Sensor(s): Model: OMeebolfical Line Leak Detector. Model: E[Mechanical'Line Leak Detector. Model: OElectr6ac Line Leak Detector Model: OMeetronic Line Leak Detector Model: OTank Overfill/High-level Sensor: Model: OTank Overfill igh:level Sensor: Model: OOther,S and model in Section E on Pa 2 OOther,S and model in Section E on Pae 2 Tank ID: Tank ID: Oln Tank Ganging Probe: Model: Oln-Tank Gauging Probe: Model: OAmm1ar Space or Vault Sensor. Model: OAnnular Space or Vault Sensor Model: OPiping Sump/Trench Sensor(s): OPiping Sump/Trench Sensor(s): . OFW Sump Sensor(s): is OFM Sump Sensor(s): Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: OElectronic Line Leak Detector Model: OElectxomc Line Leak Detector Model: OTank OverflMgh-level Sensor: Model: OTank Overfill/f[igh-level Sensor: Model: OOther,&!n ui . and model in Section E on Pa 2 OOther,S and model in Section E on Pae 2 Dispenser ID: Dispenser ID: ODispenser Containment Sensors: Model: ODispenser Containment Sensor(s): Model: O Shear Valve(s). O Shear Valve(s). ODi nser Containment Float(s)and gDig eraser Containment Float s)and Chains) Dispenser ID: Dispenser ID: ODispenser Containment Sensors: MoQODispenser Containment Sensor(s): Model: O Shear Valve(s). O Shear Valve(s). ODispenser Containment P1oat(s)and Chain(s) Containment Floats)and Chain(s) Dispenser ID: Dispenser ID: ODispenser Containment Sensors: Model: ODispenser Containment Sensor(s): Model: O Shear Valve(s). O Shear Valve(s), ODi Containment Float(s)and Chain s) ODi nser 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.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan ihoveing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a cogy of the regort (1ched all that apply): CI System set- E3 a hi ory report Technician Name(Pant): Keith lWsM __ L Signature: Service Technician No.: "062D44 T` Certification No.: 106-115-12117 License No.: 84815o Testing Company Name: Champion Precision Testing, &c Phone-No.: (661)363-7400 Pale 1 of 3 03/01