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MONIMRING SYSTEM CETIFATION For se By All Jurisdictions Within the State of Ca t ornia W AAl &d Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23, California Code of Regulations # to document testing and servicing of monitoring equipment. A separate certification or report must be Orin control panel by the technician who performs the work. A copy of this form must be provided t er/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: y r L X 5 -74 Service Station No.: Site Address: &4ft2(-1+V-P T-P, City: Zip: 1i '3 z Facility Contact Person: sU e e-N Contact Phone No.: Make/Model of Monitoring System: v 2y5 S--o Date of Testing/Service: / ® i /o-7 B. Inventory of Equipment Tested/Certified Check the gppMpriate boxes to indicate "lc euniument in serviced. Tank ID: I- 5 4, . Tank ID: ETfn-Tank Gauging Probe: Model: OIn Tank Gauging Probe: Model: [Annular Space or Vault Sensor. Model: 7P 3 10 -yty OArumlar Space or Vault Sensor Model: 2FI'p-ing Sump/Trench Sensor(s): Model: -7?'<r7a -,zz�-j ElPiping Sump/Trench Sensor(s): Model: ®Fill Sump Sensor(s): Model: OFM Sump Sensor(s): Model: 20e-chanieal Line Leak Detector. Model: S i OMechanical Line Leak Detector. Model: CElecxrotiic Line Leak Detector Model: CEleetronic Line Leak Detector Model: OTank Overfill/Kgh-level Sensor: Model: OTank Overfill/High-level Sensor: Model: pother,S and model in Section E on Eme 2 []Other,S and model in Section E on Page 2 Tank ID: '2-- Tank ID: Hfn-Tank Ganging Probe: Model: - CIn-Tank Gauging Probe: Model: 3�hmuiar Space or Vault Sensor: Model: vv--a< []Annular Space or Vault Sensor Model: D iping Sump/Trench Sensor(s): Model: 7 o-�K []Piping Sump/Trench Sensor(s): Model: OFill Sump Sensor(s): Model: OFill Sump Sensor(s): Model: C�echanical Line Leak Detector. Model: Sr l--,4 LP OMechanical Line Leak Detector. Model: OElectronic Line Leak Detector Model: OElectromc Line Leak Detector Model: OTank OverfilUHigh-level Sensor. Model: OTank OverfiIUHigh-level Sensor: Model: ❑Other,S ui . and model in Section E on Page 2 []Other, S and model in Section E on PaLe 2 Dispenser ID: t-Z. Dispenser ID: 7-K ODispenser Containment Sensors: Model: ODispenser Containment Sensor(s): Model: hear Valve(s). EMear Valve(s). 05fispenser Containment Float s)and Chain s) Mfi Containment Floats and Chain(s) Dispenser ID: 3- Dispenser ID: ODispenser Containment Sensors: Model: ODispenser Containment Sensor(s): Model: EMhear Valve(s). O Shear Valve(s). giignnser Containment Float(!)and Chain(s) ODispmtscr Containment Float(s)and Chains Dispenser ID: s-%� Dispenser ID: ODispenser Containment Sensors: Model: ODispenser Containment Sensor(s): Model: C1'Shear Valve(s). O Shear Valve(s). 22igenser Containment Float(s)and Chain(s) ODi er 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 showing the layout of monitoring equip! For any equipme capable of generating such reports,I have also attached a copy of the report;(check all that apply): ITSystem set-up AIa histo report Technician Name(Print): A-v r a �- f L� '`�'� Signature: Service Technician No.: g9 Qyl--c T— Certification No.: /+z-ry,- ` License No.: q qc;�t S-0 Testing Company Name: Champion Precision Testing, Inc Phone No.: (661) 363-7400 Pace 1 of 3 03101