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MONfAbRING SYSTEM CERTIFII .TION For Gse By All Jurisdich'ons 94thin the nate of CaliILrnia Authority Cited:Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulation5 This form mustbe used to documenttesting and servicing of monitoring equipment.A separate'certification orreport 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 Facilit Name: ! ARCO PRODUCTS COMPANY - —_ Service Station No_14932 Site Address: j 16 E HARDING WAY City: STOCKTON Zip_195204 --- Contact Person: Contact Phone N o_:. Z`n - - 3 T Facility Make/Model ofMonitoringS stem:— (J�TL S 3 �� i Date ofTestin ervice c B. Inventory of Equipment Tested/Certified Check the apprypriate Uxes to indicate specific equipment inspected/serviced: Tank ID: _ Tank ID: (` n- ankGau ing-ProbeT_— j _Model: nTankGaau •ng Probe:_ - - ; Model: nn Space or VaultSensor:_TModel: c nnularSpace or Vault Sensor Model: ipingSumJp/TrenchSensorSs): ; Model: Z • ipingSumplTrenchSensor(s� ' Model: ?c� ill Sump Sensor sZ ! Model: FillSumQSensor�s) Model: ec anical Line Leak Detector. Model: i Mechanical Line Leak Detector. Model: ectronic Line Leak Detector Model: ectronic Line Leak Detector Model: ankOverfill/High-level Sensor: ! Model: ankOverf l igh-level Sensor: Model Cher,S ec" a ui .t e andmodel in Section Eon Pa e 2 Other,S ec equip..t e andmodel inSection E on Pa e 2 Tank ID: Tank ID: n-T_ ankGaugingProbe: _LModel: In-Tank Gauging Probe: _ Model: ularSpace or Vault Sensor 1 Model: AnnularS ace or Vault Sens or_ Model: i ingSump/Trench Sensor(s): Model: P' ingSump/Trench Sensor(s) -I-Model: FI Sump Sensor(s): Model: te Sump Sensor sZ_---_i Model: e chanic al Une Le ak D ete ctor. j Model: chanicalLineLeak_Detecto_r. _;_Model: ectronic Line LeakDetectorModel: ctronic Line Leak Detector i Model: TankOverfill/High-levelSensor: j Model: i _ _ _ Tank OverfflMigh-levelSensor:_ j Model: Other,Specif y a quip.typ e and model in Section E on Pa e 190ther,Sp e c ifV a quip.typ e and model in Section E on Pa e 2 Dis enserID: —oZ Dispenser ID_— _ I 3 - q i - rs—n_se_rContainment Sensors:_ Model: Mfliqpmser ContainmentS_en-sor(s): Model: i — - he ar V alve(s)_ She at V alvA�_ ---- - ------ --- . - -— --. - - - ____ _. - ---- - - Dis enserContainmentFloa s and Chain(s) Dis enserContainmentFloa s and Ch s Dis enserID: ! Dis enserID: i nser Containment Sensors: ! Model:_ Zv Dispenser Containment Sensor(s):_ Model: j hear Valves . Sheer Valves . is ens erContainmentFlo a s and Chain(s) s'Dis ens erContainmentFlo a s and Chain(s) -DrenserID_ /IJ DispenserID: i enserContainmentSens ors: Model: DispenserGontainmentSensor(s): M-odel: - - -- -- - - _ - -- - _ f Shear V alve(s) D seri al C ontainment Flo a s an _ _ ._ ._. .� ---_ . t Fl _-- d Ch - s �D15 enser Containment Floa 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 documentwas inspected/serviced in accordance with the manufachm as' 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 a uipment. For any equipment capable of generating such reports,I Ime abo attached a copy of the report; (check all that appy). - S tem set-up_-.�-AA2f7—history ort Technician Name(Print)_ L' ,meq; Al / 1 Signature: Certification No.: License No.: TestingzCompanName: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page 1 of 3 03/01