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L��I'll D ' V0OTQRTvG SYSTEM CER Yr I ATIQN JAM 1 4 20 slY "� For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Califo� y&� Ul rf bre This form must be used to document testing and servicing of monitoring equipment. A separate cert 4lat mw±must be prepared for each monitoring system control panel 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 regulating UST systems within 30 days of test date. A. General Information Facility Name: V/Ii-<-Ro Service Station No.: Site Address: / XcSt14 r f-46 AVtF City: /11*1ty 45;FC4 ('4, Zip: Q S3 Facility Contact Person: a G<c Contact Phone No.: :-.ZC,S5 2cf� 2 gZ Makertifodet of Monitoring System: (;� lLt34R (n [_-c wt < Date of Testing/Service: /0 / Z,51/07 B. Inventory of Equipment Tested/Certified Check thc a2propriate boxes to indicatespecific a ui ment ins ected/serviceu: Tank ID: /- 7-7 Tank ID: 3 - i7, F'Sr Z C'fr-Tank Gauging Probe: Model: _ _ Z Orn -Tank Gauging Probe: Model: p?�rnular Space or Vault Sensor: Model: 11jo251 o t o ao oo annular Space or Vault Sensor Model:. Z' C 1 OTC Q>sping Sump/Trench Sensor (s): Model: - z,-70 2c o 0 1 o EDI-iping Sump/Trench Sensor (s): Model: ,�Wo.t aoci ❑Fill Sump Sensor (s): Model: e- p 2Gao []Fill Sump Sensor (s): Model: (Mechanical Line Leak Detector. Model: 31aechanical Line Leak Detector. Model: G J -20 Q o []Electronic Line Leak Detector Model: []Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, S ecifv aqui and model in Section E on Page 2 ❑Other, Specify equi2. tMe and model in Section E on Pae 2 Tank ID: a - `t 1 Tank ID: C3rn-Tank Gauging Probe: Model: SG-- 2 ❑In -Tank Gauging Probe: Model: EAnnular Space or Vault Sensor: Model: x t 3;yoq ❑Annular Space or Vault Sensor Model.- (ping Sump/Trench Sensor (s): Model: , 4c� 90 Zccro t c ❑Piping Sump/Trench Sensor (s): Model: _ [Till Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: D;�chanical Line Leak Detector. Model: /_1) 2oao []MechanicalLine Leak Detector. Model: ❑Electroriic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-levet Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, S2ecia equie and model in Section E on PaLe 2 ❑Other, Specia aqui and model in Section E on Pa e 2 Dispenser ID: r-7- Dispenser ID: 7-'? ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: Gear Valve(s). ['Shear Valve(s). 0 is enser Containment Float(s) and Chain(s) 2Ms enser Containment Float(s) and Chain(s) Dispenser ID: 3-y,Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: _ 0"S -hear Valve(s). ❑ Shear Valve(s). 3I5is enser Containment Float(s) and Chain(s) ❑Dis enser Containment Float(s) and Chain(s) Dispenser ID: _ 7 -6 Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model _ L'1'Shear Valve(s) ❑ Shear Valve(s). p'6is nser Containment Float(s) and Chain(s) ❑Dis enser 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): Fz System set-up E;rAIa history Technician Name (Print): Acv, j L, �(r��su/zr-� Signature:t� Service Technician No.: Certification No.: Testing Companv Name: c7 '1S,i V f u 7- .1 ITTY2 License No.: Champion Precision Testing, Inc _ Phone No. (66 t) 363-7400 Paee I of 0;01