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MONITORMG SYSTEMCERTIFICA11ONa For Use By A11.Iurisdietions 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 to certification or repo rt in st:be rred for mm�itoriniC sv 1 1 by the technician who performs the work. A copy of this form must be provided to the tank system / or. The / or must sulhmit a copy of this form to the local agency regulating UST s,�ms within 30 days of test date. A. Genersd InfornistioRy Service Station No.: Facility N C �e� r / n ,lZ� City: k to�f�r.Pa___T____: Zip: Site Address: �,�' ® .,_, Facility Contact Person: Contact Phone No.: /Model of Monitoring t/ JZ ��S"' 1 S.'CrJ Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check the to le c nlemeat im servltxti: Tank ID: , T ID: MilkTank Gauging Model: 4 �.! -Tank Gauging Probe: Model: &el ai = S or Vault Model: ® T 1Q-4® ax Spate or Vault Sensor �- 9UWSumpjTmnch (s): Model: 40 '),0g Sump/Trench Seng(s): Model: o OFfii S (s): Model: []Fill Sump Sensor(s): Model: echanical Line Leak Detector. Model: 04 L Q 06chanical Line Leak Detector. Model: Ite ef 4 0 ClElectronic Line Leak Detector Model• OElectronic Line Leak Detector Model: [3Tank ll/Mgh-level l: OTank Overfill"gh-level : r S model in on E on Pa 2 S and model in Section E on 2 T : T ID: ®In-T g Probe: el: Oln-T ng be: l: OAmmlff Sp=or Vault r: Model: OAnnular Space or Vault Sensor 1: ®Pi . g S h (s): Model: ❑Piping Sump/Trench Sensor(s): Model: OFill Sump Sensor(s), l: OFill Sump Sensor(s): Model: OMechafticOl Line Leak Detector. Model: [!Mechanical Line Leak Detector. Model: [3f-lectrtmic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: OTank Overfill/Aigh-level Sensor: Model: OTank Overfill/High-level Sensor: Model: ® S model in Section E on P 2 []Other S ui . and model in Section E on Pa 2 Dispenser ID: I ~� 2.. Dispenser ID: �� Z-1 ®Di Contac t Sensors: Model: 0D' ser Containment Sensor(s): Model: _ Vah*s) — "Ve(s). MCdtltaitintent Float s and Chains i neer Containment Floats and Chain s) D ID: �` DispenserID: OMSPenw ContainmentSensors: Model: ODispenser Containment Sensor(s): Model: V s). V s)' Containment Floats and,gLMs Containment,Floats and Chain s Dispenser ID. Dispenser ID: ODispenscr Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: _ O Shear valve(s). ❑ Shear Valve(s). ODLvmw Co t FlOO s and Chaial s [3I)jgescr Containment Floats and Chain(s) *[f thehdlitycontainmore tanks or dispensers,copy this form. Include information for every tank and dispenser at this facility. C. Ce cation - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer'guidelines. .Attached to this Certification is information(e4 manufacturers' checklists)necessary to vev*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 a co of the ort;(check all that apply): 13 System set-up ® hi ort Technician Name(Print): a r-h,� Signature: " =' Service Technician No.: S O `� Z., Certification No.: License No.: Testing Company Name: Champion Precision Testing,Inc Phone No.: (661)363-7400 Rate t of 3 03/01