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0 0 MONITORING SYSTEM CERTIFICATION For Use By.411.1urisdictions 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 separate certification or report must be pLepared for each monitor r r, 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 dus form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Service Station No.: Zite Address: 7A City: e LA72:; op Zip: Facility Contact Person: N.,6 /r— , Contact Phone No.: Make/Model of Monitoring System: T,!� � - -7-G' B. Inventory of Equipment Tested,/Certiried MM to indicate Date of Testing/Service: eY' - e '-j T r.TaA Dispenser ID: Tank ID: 013!yir Containment Sensor(s): Model: M"Shear Valve(s). Gauging Probe: Space or Vault Sensor: Sump/Trench Sensor (s): OF% Sump Sensor (s): (�f4echanical Line Leak Detector. Model: Model: 0 21 -c-),T qaffe�li Model VIV-10e, 0 Model: 1-2- �U;Tauk Gauging Probe- a.-Nimuln Space or Vault Sensor ping ump/Trench Sensor (s): S ump Sensor (s): Line Leak Detector Model: Model: 0�1 4e,7T Model: 6;71�0 A2 Model: Model: i-ce OElectronic Line Leak Detector Model: DElectronic Line Leak Detector Model: OTank Overfillffligh-level Sensor Model: iwi fni#:r,er. S -r ealfiv. tvm and model in Section E on Page 2 oTank Overfill/High-level Sensor Model: [30tker�, Specequip. Ve—x4 D Tank I: Dispenser ID: Tank ID: 013!yir Containment Sensor(s): Model: M"Shear Valve(s). Elln-T=kGauging Probe: Model: oin-Tank Gauging Probe: 7 �, Model: EiAnnular Space or Vault Sensor: Model: OArmular Space or Vault Sensor Model. opiping Sump(Trench Sensor (s): Model: []Piping Sump/Trench Sensor (s): Model: []Fill SumpSensor (s): Model: ■]Fill Sump Sensor (s): F- Model: OMecbanical Line Leak Detector. Model: OMechamcal Line Leak Detector Model: ElElectronic Line Leak Detector Model: OElectronic Line Leak Detector Model: E]Tank Overfillffligh-level Sensor: Model: [:]Tank overfillffligh-level Sensor: Model: 94r[Yer- S-xt7j4i,1v,:__rui1D. tq-,-- and model in Section E on Pagc_�,, equip. ty 00ther, Specify _pc and model in Section E on, Pa 2 Dispenser ID: 4L 2— Dispenser ID: ®D' user Containment Sensors: Model: S Valve(s). 013!yir Containment Sensor(s): Model: M"Shear Valve(s). ispenser Containment Float(s) and Chain s) ispenser Containment Float(s) and Chain(s) Dispenser ED: Dispenser 0: el ODA r Containment Sensors: Model: ODispenser Containment Sensor(s): Model: bear Valve(s). Valve(s). 9- ispenser Containment Float(s) and Chain(s) — u ser Containment Float(s) and Chain(s) ;1 Dispenser ID: ®Dispenser Containment Sensors: Model: Dispenser ID: DDisvenser Containment Sensor(s): Model: 0 Shear Valve(s) F1 Shear Valve(s). OD'penser Containment Float(s) and Chaig(s}. oDispcnser 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 eqw'pmge I For any equiping"'apable of generating such reports, I have also attached a co v of the report; (check all that apply): USystem set-up AlJtory report Technician Name (Print): �Te-,:�J-rd Signature: Certification No.: f, z License No.: Testing Company Name: Champion Precision Testing, Inc Phone No.: (916) 927-1557 'Plaup I of 3