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MONIT NG SYSTEM CERTIFIC,� .TION 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 report 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: ARCO PRODUCTS COMPANY Service Station No.: 4932 Site Address: 16 E. Harding Way City: Stockton Facility Contact Person: Contact Phone No.: Zip 95204 Make/Model of Monitoring System: Vee9C4,- . 4 c, P -L 7'L S Date of Testing/Service: i 2 j B. Inventory of Equipment Tested/Certified Check the annronriate boxes to indicate specific equipment inspected/serviced: 313 Tank ID: R7 Tank ID: S, c ❑In -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: [Annular Space or Vault Sensor: Model: -7 9,1131e - yb q ❑Annular Space or Vault Sensor Model: biping Sump/Trench Sensor (s): Model: CgKiping Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: echanical Line Leak Detector. Model: ❑Njechanical Line Leak Detector. Model: Xlectronic Line Leak Detector Model: c 9 i lectronic Line Leak Detector Model: (� — ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, SpeciLy equip. a and model in Section E on Page 2 ❑Other, S ecify aqui a and model in Section E on Page 2 Tank ID: Tank ID: ❑ln-Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: [��j ular Space or Vault Sensor: Model: -7-9,v3-7c0 c ❑Annular Space or Vault Sensor Model: [t�P piing Sump/Trench Sensor (s): Model: -29y3 []Piping Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: 2chanical ctronic Line Leak Detector Model: COT ❑Electronic Line Leak Detector Model: []Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, SpeciLy aqui a and model in Section E on Page 2 ❑Other, S2eciEy equip. a and model in Section E on Page 2 Di nser ID: Xpe Z -7-T+_Wv Dis eraser ID: . Containment Sensor(-): Model: 7`54 "e spencer Containment Sensors: Model: -Zc eraser -2,9 [Shear Valve(s). Shear Valve(s). ❑Dis eraser Containment Float(s) and Chain(-) ❑Dis eraser Containment Float(- and Chains Di enser ID- Sensors: tF Model: �38e Dis enser ID: 7 Containment Sensor(s): Model: spencer Containment 7 Zoe' penser Shear Valve(s). Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(-) ❑Dis enser Containment Float(sl and Chain(s) enser ID: y/ D Dispenser ID: penser Containment Sensors: Fisshear Model: �Sy �r� ❑Dispenser Containment Sensor(s): Model: Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) ❑Dis enser Containment Float(-) 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; (chejc� all that apply): System set-up )b Alarm history report Technician Name (Print): f�,.1/174g,-,�Signature: r... wr Certification No.: License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222 Page l of 3 03/01 Monitoring System Certification