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f fs' <br /> Champion P.O. Box 13059 <br /> Sacramento, CA 95813-3059 <br /> Precision Tank Testing <br /> License No. 73848 CA 800-660-9443 <br /> NEV 800-949-9443 <br /> t (916) 927-1557 <br /> -Fax: (916) 927-7345 <br /> 11IONITORINTG SYSTEM EQUIPMENT CERTIFICATION <br /> Date of Testing/Servicing: 1 O 117 Facility Name <br /> Site Address: I Liifl E , I A-i"t�-�iZ cam <br /> City: Zip: ''.n <br /> Facility Contact Person: <br /> Contact Phone No.: <br /> MakeUodel of Monitoring System(s):� L� �~, <br /> Location of Control Panel(s): &aj,,, 7?4N-�P� <br /> Make./Model of Line Leak Detector(LLD): —r�m (,o Lt VJ <br /> LLD Leak-Threshold: $. Q•p-m• <br /> Complete the following checklist: <br /> ❑ Yes No* Monitoring system is operable per manufzcturer's specifications! <br /> Yes ❑ No* Audible alarm is operatio=7 <br /> '7 Yes EQ No• Visual alarm is operationaD?Yes Now Monitoring system is secured from unauthorized tampering? <br /> ❑ Yes ❑ T'o• For pressurized piping systems,do the turbines automatically shut dowzt if the monitoring system detects a leak, <br /> N/A fails to operate,or is electrically disconnected? If yes,which monitoring devices initiate positive shut-down? <br /> ❑ Yes ❑ No; For monitoring systems which serve as tank overfill warning devices, does the overfill warning function operate <br /> N/A properly? If so,at what percent of tanl;capacity does the alarm trigger? <br /> In the commenu section below,describe how and when these deficiencies will be corrected. <br /> Check the appropriate boxes to indicate specific equipment inspected/sen•iced: <br /> Tank ID No.: Tank ID Aro.: Tank ID No.: <br /> Annular Space Sensor Tank ID No.: <br /> !7 Piping Sump Sensor Annular Spiciest sor Arutular Space Sensor <br /> Piping Sump Sensor Annular Space Sensor <br /> In Cnu¢ing be ❑ In-tank Gauging Probe Piping Sump Sensor ❑ Piping Sump Sensor <br /> ❑ Dispenser Continment Scnsor(s) ❑ Dispenser Containment Sensor(s) ❑ Dispenser Conitrilrurioent Sensor(s) ❑ Dispenser be 13 C ntainment Sensors) . <br /> ❑ Mechanical Linc Leak Detector ❑ Mechanical Linc Leak <br /> Detector ❑ Afechanical Line Leal;Detector ❑ Mechanical Line Leak Detector <br /> Electronic Linc Leak Detector �Q] Electronic Line Leal Detector <br /> Electronic Line Leak Detector ❑ Electronic Line Leak Detector <br /> Comments: (a ;e <br /> IT <br /> tl,.?w (, i � t ,� t tom.i. ,tom '•' t� <br /> .1 Qq' <br /> I certify that the equipment identified above was inspected/sen-iced in accordance with manufacturers' guidelines. Attacbed <br /> to ibis Certification is information (e.g. manufacturer's checklists, etc.) necessary to verify that the above information is <br /> correct and to describe any repairs,replacement,or recalibration of equipment. <br /> Name of Qualified Technician(print):O i I\%M�'. (,/,#,Ac�M 1EU <br /> �• Signature: <br /> Testing Company Name: <br /> LV2=� <br /> Phone No.: p0 O.. <br /> LT-036 <br /> Rev.0/17197 <br />