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MONITORING SYSTEM CERTIFICATION For Use By All.lurisdictions Within the State of California Authority Cite& Chapter 6.7, Health and Safety Code; Chapter 16,Division 3, Title 23, California This form must be used to document testing and servicing of monitoring equipment. A separate certsfi grepared for each monitoring system control Mel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regN"9-U41?4%ms within 30 days of test date. SA. General Information ERMCES Facility Name: Service Station No.: Site Address: 3-0G City: 1-,411.1-ep Zip: Facility Contact Person: Contact Phone No.: YZ�- 07-2-3 Make/Model of Monitoring Systerw. Date of Testing[Service.- B. Inventory of Equipment Tested/Certited Check the Mpropriate boxes to indicate Vecific quipj!!ent ins 3ected/serviceA. Tank 11): - 51 Tank ID: On-Tank Gauging Probe:' Model: .V;p W C- t Oln-Tank Gauging Probe: Model: Mikhmilar Space or Vault Sensor: Model: Zf!!&?AoF-Ye,-,7 OAnnular Space or Vault Sensor Model: [Wiping Sump/Trench Sensor(s): Model: 7!9 W7F- OPiping Sump/Trench Sensor(s): Model: DFill Sump Sensor(s): Model: DFill Sump Sensor(s): Model: OtTechanical Line Leak Detector. model: OMechanical Line Leak Detector. Model: DElectronic Line Leak Detector Model: OEIectronic Line Leak Detector Model: oTank Overfill/High-level Sensor: Model: oTank Overfillfiligh-level Sensor: Model: 00ther, Sand model in Section E on Page 2 00ther, Spqq!fK.qgyiip andmodelinS Section ecti 2 TA,=e Tank ID: Oln-Tank Gauging Probe: "-v Model: Din-Tank Gauging be: Model: ular Space or Vault Sensor: Model: j;,?dj4 OAnnular Space or Vault Sensor Model: OPiping Sump/Trench Sensor(s): Model: k&-rlo DPiping SumpTrench Sensor(s): Model: OFill Sump Sensor(s): Model: DFill Sump Sensor(s): Model: 90&chanical Line Leak Detector. Model: $7-)0-1,Ve- 0 OMecbanical Line Leak Detector. Model: OElectionic Line Leak Detector Model: OElectronic Line Leak Detector Model: OTank Overfill/High-level Sensor: Model: OTank Overfin4ligh-level Sensor: Model: 00ther, § and model in Section E on Pa 2 00ther, § w �p- andmodel in Section E on Page.2 Dispenser ID: Dispenser ID: z—15--- 0Dispenser Containment Sensors: Model: DDispenser Containment Sensor(s): Model: fig'Shear Valve(s). ('Shear Valve(s). 901spenser Containment Float(s)and Chain(s)_ 00r enser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: ODispenser Contairmient Sensors: Model: DDispenser Containment Sensor(s): Model: [&Shear Valve(s). 0 Shear Valve(s). MUispenser Containment Float(s)and Chain(s) 0Di9?9=Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: ODispenser Containment Sensors: Model: 013ispenser Containment Sensor(s): Model: 91-1hear Valve(s). 0 Shear Valve(s). Containment Float(s)and Chain(s) E]Dig!Snser 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 verify 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 copy of the report;(check all that apply): Wsysleni set L Alarm sto report Technician Name(Print): 4z Signature: -16 ?K Service Technician No.: .6o 4e� —/, -Z Certification No.: cam, �-;7 License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (661)363-7400 Page 1 of 3 03/01