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MONFARING SYSTEM CERTIF CTION 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, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment A separate certification or Igport mug 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 Inforization Facility Name: Service Station No.: Site Address: oe�,� Ow. 4) - Zip: Facility Contact Person: Contact Phone No.: Make/Model of Monitoring System: /001 44Z0"Z- 7--Z-5—240 Date of TestingISemce: B. Inventory of Equipment Fest ecl/Certified Check the appropriate bo*es to indicates e in pected/serviced: Tank D:): Tank ID: Wfm-Tank Gauging Probe- v Model: e;57W& lal'n-Tank Gauging Probe: Model: 'AP071ve O'Cimular Space or Vault Sensor. Model: kt,,,4,ZE12-JI459 0,16mular Space or Vault Sensor Model: zfv-�-- Nfi-p-ing Sump/Trench Sensor(s): Model: ing Sump/Trench Sensor(s): Model: lk-VI(ma OFW Sump Sensor(s): Model: ORU Sump Sensor(s): Model: 9WAechanical Line Leak Detector. Model: L a g!;2!qC; WAechanical Line Leak Detector. Model: OE]ectromc Line Leak Detector Model: OElectronic Line Leak Detector Model: OTank Overfill/High-level Sensor. Model: OTank Overfill/High-level Sensor Model: 022!SE,S j?Fm Section !ci& ec(urp-tym-and model in E on Page 2 00ther, 2qq!p. type and model in Section E on Ea e 2 Tank ID: 7-7'� Tank ID: oin-Tank Gauging Probe:' Model: Oln-Tank Gauging Probe: Model: OAnnular Space or Vault Sensor Model: OAn lar Space or Vault Sensor Model: OPiping Sump/Trench Sensor(s): Model: d OPiping Sumptrzench Sensor(s): Model: OFill Sump Sensor(s): Model: OFRI Sump Sensor(s): Model: EM=hamcal Line Leak Detector. Model: L 0,a< OM cal Line Leak Detector Model: OElectronic Line Leak Detector Model: OElectronic Line Leak Detector Model: OTank Overfill/High-level Sensor. Model: OTank Oveffiffliffigh-level Sensor. Model: 00ther,Sand model in Section E on P 2 00ther, Sand rvPe model in Section E on 2 Page 2E_&MM - Dispenser ID: Dispenser ID: ;>- -4?- Wispcnser Containment Sensors: Model:PW3SV-,jgde WOispenser Containment Sensor(s): Model: UrShear Valve(s). vaws). OD1§=Containment Float s)and Chains) ODispenser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: Mispenser Containment Sensors: Model: ODispenser Containment Sensor(s): Model: eShear Valve(s). 0 Shear Valve(s). OpiContainment Float(s)and Chain(s) 01)i§nEi Containment float(s)and Chain(s) Dispenser ID: Dispenser ID: Mbispenser Containment Sensors: Model: .20$f, ODispenser Containment Sensor(s): Model: 6;Sh;ar Valve(s). 0 Shear Valve(s). ODiTenser Contamment_Eoat(s)and Cham(s) 01)inser Containment Float(s)and Chains) *If the facility contains more tanks or dispensers,copy this form- Include information for every Link and dispenser at this facility. C. Certification - i certify that the equipment identified in this document was ins serviced in accordance withthe 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 eqtu*pmen capable of generating such reports,I have also attached a copy of the report;(ekerk all that apply): ystem sethihi y report Technician Name(Print): Keith Huston Signature: Certification No.: deg 9- 0-1,- 7 License No.: Testing Company Name: Champion Precision Testing,Inc Phone No.: (916)927-1557 X3411