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12/01/2005 12:17 16613634 CHAMPION PT INC PAGE 05 MONITORING SYSTEM CERTIFICATION For Use.8y/111.Jurisdicli0ns Within the State of Califomia ,'la�thority Cited:Chapter G-7, Health and Safety Code;Chapter 16,I?wWon 3, 1'itte 23., Califi0mia 'ode of Regulations This form musk be used to document testing and semcing of monitoring equipment- A serrate certil cation or mnoxt must be _ far each mnnitoring system control 0201 by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The ownerloperator ztiust submit a copy of this form to the local agency regulating UST s."tems within 30 days of test date- A. Gelner9l)[ttformatiOn Service Station No.: Facility Nance: P,4 Site : �� 7C,1�S��°n City: p--.M _ Zip: Facility Contact Person: Contact Phone No.: MakelModd of Monitoring System: � f~�,5��'0 ate of Testing/Service: B. Inventory of Equipment Tested/Certified Chak the 29 ate bon to indicatespedfic equilment. se Tank ID: Tank ID: ®'ln-Tauk Gauging]Pr Model: /��S7 G" f DIn-Tank Gauging Probe: [ mnular Space or Vault Sensor: Model: _ _ i�9d''`J�Q ❑Anm lar Space or Vault Sensor Model: Wiping SuntpT=ch Sensor(s): Model: E3Piping Sump/Trench Sensor(s): M011d: ❑1+411 Sump Sensor(s): Model: ❑bill Sump Sensor(s): Model: eehardcal Line Leah betector. Model: .57",O Gla omechanical Line Leak Detector. Model: pElectronic Lire Leak Detector Model: ®Electronic Lige Leak Detector Model.: []Tank OverblMgh-level Sensor: Model: ❑Tank overt'illfEHigh-level Sensor: Model: pother,S and model in Section E on Page 2 ©C+ther S and model in SeWon E on Page 2 Tank ID- Tank ID, ging g el: pin Tank Gauging be: 1: Spam or Vault Sewwr: Model: �',3, e- �' OAnnaLu Space or Vault Sensor Model: opir.g S raoualtSensor(s): Mexkt: 'Pea - m ❑Piping S reach Sensor(s): Model: ElFill Sump Seusox(s): Model: []Fill Sump Sensor. (s): Model: f fl techamicai Line Leak Detector. Model: S Lp C3Mechanieal Line Leak Detector. Model: ❑Blectronic Linc Leak Detector Model: pEJecrmnie Lime Le Detector Model: 12Ta uk OverfilM911 level Sensor. Model.: C3Tank Qvcrfill/Higb-levct . Model: pC}ther,S and in Section E on Pa 2 ❑fiber and model in Section.E on P 2 Dtspenser TA: D' m: oDispenser Containment Setters: Model: omspemser Conraimneut Sens'crr(;s). Model: athear Valve(s). 2TSbear Valve(s). w5Containment 1~loat s and Chains � Contain me t Moat(s2 and Cbailt s Dispenser 1D: Dispenser ID: ❑ m Dispenser Containment Sensom: Modei: Mispenser Contaimt►esrt Sensor(s): Model: cKhev Valve(s)- ❑ Shear Vatve(s). Containmeutt Floats and Chain(s) oDigMser Contaitueent Floats and Ch!!!g9 Dispenser ID: Dispenser ID: [:]Dispcmlr CoOntjinment Sensors: Model: ❑Dispenser Containmtetrt Sensor(S): Model.: valve(s). p Shear Valve(s). VWIWenser Containment Floats and Chain s) ODiggser Containment k3 s and Chain(t) *rf the facility contains more tanks or dispensers,copy this form. include information for every tank and dispenser at this facility. C. Certifleeation - I certify that the equipumnt identmed In this document was Inspec"sermiced in accordance with the manufacturers'guidelines. Attached to this Certification is ioaformatian(erg manufacturer' cheehl@ssts)necessary to verify that this information is correct and a Plot Plan showing the layout of mm?itaring equipment. For anyequipment capable of generating such reports.T have also attached a Co of the report: (e"all that apply): 11Syst"i$etrulJostoly mport Technician.Name(Print): ,�7-rj1 �G.s i� Signature: •e�`" ` Service Technician No.: eo go Y -U7� CeVrtification No.; ®06_&>S`' License No.: Testing Comp my Name: Champion Precision TegE&.ine _. JPbone No.: (661)363-7400 03M Peres 1 of 3