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MON*RING SYSTEM CERTIION For Use By All Jurisdictions Within the State of CaliforniaCa i or Authority Cited: Chapter-6.7, Health and Safety Code; Chapter/6, Division 3, Title 23, California Code of Regulations Thi sforin 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 foam 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 day-sof test date. A. General Information Fac ility Name: ARCO Service Station No.: 6335 Sita Address: 4855 St Hwy 99 / , City: Stockton Zip: Facility Contact Person: �.l Ot�ly 5 C fail,/ Contact Phone No.: 2o9 — 6 d - 3 3 3 5 Make Model of Monitoring System: '72 j —'� �' l f Y� _ Date of Testing/Service: 2/13/03 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific aqui rent ins ected/serviced: Tank ID: ` Tank ID: �) ❑In-Tank Gauging Probe: Model:' t A ❑In-Tank Gauging Probe: Model: all-mular Space or Vault Sensor: Model: ?qNJ ular Space or Vault Sensor Model: (Piping Sump/Trench Sensor(s): Model: '• — 4 t mg Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fil p Sensor(s): Model: ❑Mechanical Line Leak Detector. Model: A echanical Line Leak Detector. Model: L p y c; v (Electronic Line Leak Detector Model: ectronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: pTank Overfill/High-level Sensor: Model: ff[10t1hijer, S ecify a ui a and model in Section E on Pa e 2 ❑Other,S eci a ui . e and model in Section E on Pa e 2 k D: �/ Tank ID: Tank Gauging Probe: Model: []In-Tank Gauging Probe: Model: �mular Space or Vault Sensor: Model: ?;y's.3fi'; []Annular Space or Vault Sensor Model: rping Sump/Trench Sensor(s): Model:-2 9l sL []Piping Sump/Trench Sensor(s): Model: ❑Fil ump Sensor(s): Model: []Fill Sump Sensor(s): Model: echanical Line Leak Detector. Model: L D4o6> []Mechanical Line Leak Detector. Model: lectronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: Tank Overfill/High-level Sensor: Model: []Tank Overfill/High-level Sensor: Model: ❑Oilier,S eci equilp. e and model in Section E on Page 2 ❑Other,Specify e ui . =e and model in Section E on Page 2 Dispenser ID: OmJ — I r Dispenser ID: ,Dispenser Containment Sensors: Model:�qy�,r -2c; f ❑Dispenser Containment Sensor(s): Model: shear Valve(s). ❑Shear Valve(s). []Dispenser Containment Float(s) and Chain(s) ❑Dis enser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: []Dispenser Containme=Float(s)and odel: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) ❑Dis enser Containm (s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: []Dispenser Containment Sensor(s): Madel: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) ❑Dis enser Containment Float(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 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, 1 have also attached a copy of the report;(check all that apply): U..System set-up rYfarm history report Technician Name(Print): Craig Block Signature: YL, c I �11 1 Certification No.: /2�/ License No.: 58"8 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (916)858-1090 03/01 Page t of 3 Monitoring System Certification