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MONITORING SYSTEM CERTIFICATION For Use By All.lurisdictions Within the State of California ;authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3 t Title A s 23, California C is ertfilfttion ode of r 3, must be ons This form must be used to document testing and servicing of monitoring equip pre d for each monitoring system con otrolelrator must submit a by the technician hofperforms copy this form to he local agency regulating UST systems ner to the tank system owner/operator. The ow pe within 30 days of test date. A. General Information- Service Station No.: Facility Name: lV Zip: Site Address: _ l6 rCity: Facility Contact Person: � Contact Phone No.: Date of Testing/Service: Make/Model of Monitoring System B. Inventory of Equipment Tested/Certified Check the ro rlate boxes to indicate s ecfic equipment dna Tank ID'�� r�O�Tank : ❑,In-Tank Ganging Probe: Model: Gauging Probe: Model: ar Space or Vault Sensor: Model: Ll �0 �-�Q ❑Acular Space or Vault Sensor Model: Model: ®Piping Sump/Trench Sensor(s): Model: Sump/Trench Sensor(s): Model: ump Sensor(s): Model: ®Fill Sump Sensor(s): anical Line Leak Detector. Model: pMechanical Line Leak Detector. Model: onic Line Leak Detector Model: ®Electronic Line Leak Detector Model: level Sensor: Model: ❑Tank OverfilUHigh-level Sensor: Model: Overfill/High- ui . and model in Section E on Pa2, S and model in Section E on Pae 2 ❑Other S Tank ID: Tank ID: Madel: On-Tank Gauging Pr Model: ❑ln-Tank Gauging Pr ®Annular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: Model: []Piping Sump/Trench Sensor(s): Model: ®Piping Sump/Trench Sensor(s): ❑Fill Sump Sensor(s): Model: ®Fill Sump Sensor(s): Model: (]Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ®Tank Overfill/High-level Sensor: Model: ❑Tank OverfilMgh-level Sensor: Model: 00her, S ui , tvm and model in Section E on Pae 2 ❑Other, SEcify 2quip. and model in Section E on Pa e 2 Dispenser ID: Dispenser ID:❑Dispenser Containment Sensor(s): Model: pDispenser Containment Sensors: Model: ® Shy Valve(s). ❑ Shear Valve(s). QDispenser Containment Float(s)and Chain(s) ^Dis iiser CanWinnent Finat(s)and Chain(s) Dispenser ID: Dispenser ID: . pDi r Containment Sensor(s): ;Model: ❑Dispenser Containment Sensors: Model: ® Sh�near Valve(s)p Shear Valve(s). ❑Di Containment Floa s)and pDi neer Containment Floats and Chain s Dispenser ID: Dispenser ID: Di r Containment Sensor(s): Model: ❑Dispenser Containment Sensors: Model: ❑ sperm ❑ Shear Valve(s). p Shear Valve(s). (pDi . neer Containment Floats and Chains pDi nser 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' checklists)necessary to verity that this information is correct and a Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports.I have also attached a co of thM) 7, F��t ht apply): ® System set-up Technician Name(Print): Signature:Service Technician No.: S %+ Certification No.: License No.: Testing Company Name: Champion Precision Testing,Inc Phone No.: (661) 363-7400 03/02 Rage 1 of 3