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MONITORING SYSTEM CERTIFICATION <br />For Use By All .turisdictions Within the State of California <br />Authority Cited: Chapter 6. ?, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations <br />A s •rate ��� Or —rgmn must be <br />This fbrtn must be to document testing and servicing of monitoring equipmentthis form must be provided <br />sv m WMI tsanel by the technician who performs the work. A cry re ms <br />to the m -o <br />The owner/ r must submit a copy of this form to the local agency regulating UST system <br />within 30 days of test date. <br />A. General Information ( Service Station No.: <br />Facility Name: <br />t <br />Site tie- i°y City: Zip' -- <br />Contact Phone No.: <br />Facility Contact Peon: <br />l C <br />Date of Testing/Service: <br />Make/Model of taring m: c <br />w 1 <br />Tank Fr <br />Probe- <br />r-Amngar Spaceor <br />y <br />r <br />r <br />.a r m <br />1 <br />Model: <br />lir <br />'YI + ,, . <br />Model: <br />■ <br />- 1mA <br />a' rW <br />Line Leak Detector <br />m/'[3Electronic <br />,, <br />- <br />11 <br />� <br />■ r 1: i t 1 m <br />-- <br />+ <br />1 <br />Section r <br />qwl q M !' 1 / modelC=- <br />Tank LID: <br />1 Ir <br />._actModel: <br />■ Gauging <br />,, m r:o <br />mm <br />e/ <br />■ 1 ,,, 1 til, 1 m :,model: <br />Elfill Sung) Sextsor (s): <br />mom: <br />CIMechanical.i' Leak Detector.Model: <br />■m m 1 1~ v `m <br />• 1' <br />■ e. t 1 1 1 v+ Detector <br />rr <br />/ till' <br />i a <br />. <br />and model 1' Lne, m l m 1 <br />: ..._ <br />■ � t -: m a+ ±•1 r 't" <br />Dispertm ID: <br />r D <br />r ch" mcontainment, <br />of <br />0 r r' 1 m 1 t; t a. +'Model:■ <br />g'Sjbicar Vative(s). <br />l7r ,r r' 1 1 m 1 <br />r' m; 1r. <br />■r en Containment S`.!'m. <br />y <br />m'r li <br />Dispenser <br />Model: <br />y <br />e i -r' <br />Dispenser ID: <br />ElDispenset Containment Sensors: <br />r : 1oD: _.. <br />orlispenser Containinent Sensor(s): <br />is <br />Model: <br />Model: <br />■ Shm <br />. vt ,, 'P. 1 <br />L{Y <br />*If the facility con more or di form. <br />, copy this Inc information for every tank and dispenser at this facility. <br />C. Ce eation - I certffy that the equipment identified in this document was ins serviced in accordance with the <br />manufacturers' guidelines. Attached to this Certification is information (egmanufacturers' checklists) necessary to verify that this <br />information is correct and a Plot Flan showing the layout of monitoring equipment. For any equipment capable of generating such <br />reports. I have also attached a NCthe ort; (check all that ): ❑ system9et-UTechnician Name (Print): Crh Signature: <br />Service Tlehnic an No.: . <br />Certification No.:i mac( License No.: <br />Testing Company N Champion Precision Testing, Inc Phone No.: (561) 363-7404 <br />saror <br />Pane t of 3 <br />