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MONI WIRING SYSTEM CERTIFOATION 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.: 6335 Site Address: 4855 ST HWY 99City: STOCKTON Zip: 95208 - Facility Contact Person: S*„'// /e.*-eA— Contact Phone No.: �a� s z �t�� X Make/Model of Monitoring System: t/QCdeaFOti+I (��J" Date of Testing/Service: 10-LX bZ B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: 7 Tank ID: $ `1 ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: VlAnnular Space or Vault Sensor: Model: 14 3 110-'46 [iffAnnular Space or Vault Sensor Model: '79 it 39 a-K09 Piping Sump/Trench Sensor(s): Model: 9 Y Yo' S ®Piping Sump/Trench Sensor(s): Model: 11 K 3 S�-lti A Fill Sump Sensor(s): Model: 4117ill Sump Sensor(s): Model: ❑Mechanical Line Leak Detector. Model: [BMechanical Line Leak Detector. Model: LQ}-d-tTd [y]Electronic Line Leak Detector Model: C-0-T- ❑Electronic Line Leak Detector Model: []Tank Overfill/High-level Sensor: Model: []Tank Overfill/High-level Sensor: Model: []Other, Specify equip. e and model in Section E on Pae 2 []Other,Specify equip. e and model in Section E on Page 2 Tank ID: �} / Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: Annular Space or Vault Sensor: Model: 71t ;9o, . ❑Annular Space or Vault Sensor Model: OPiping Sump/Trench Sensor(s): Model: 11114 ZV-7,b ❑Piping Sump/Trench Sensor(s): Model: §Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: RMechanical Line Leak Detector. Model: >-d-ab []Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: []Other,Specify equip. e and model in Section E on Pae 2 ❑Other, Specify equip. e and model in Section E on Pa e 2 Dispenser ID: L Dispenser ID: I—Y Dispenser Containment Sensors: Model: 7 [Dispenser Containment Sensor(s): Model: 7 i k3Fo 7a'' Shear Valve(s). [,� Shear Valve(s). []Dispenser Containment Floats and Chain(s) ❑Dis enser Containment Float(s)s and Chain(s Dispenser ID: 3 Dispenser ID: 7 -/,Q Dispenser Containment Sensors: Model: 744 So-'bF INDispenser Containment Sensor(s): Model: 79k'4190-24V [7R Shear Valve(s). fy3 Shear Valve(s). []Dispenser Containment Floats and Chains ❑Dis enser Containment Floats and Chain(s) Dispenser ID: 3'` Dispenser ID: /J_/t— IBDispenser Containment Sensors: Model: '7"SSo-Aoh Dispenser Containment Sensor(s): Model: ti 3 w i1� 2 Shear Valve(s). B Shear Valve(s). []Dispenser Containment Float(s)and Chains ❑Dis enser Containment Floats 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-1 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; (check all that apply, 'R System set-up 'Alarm history rregort Technician Name(Print): ly.p� �y�n Signature: 61T i, Certification No.: 31;it ; License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page I of 3 03/01 Monitoring System Certification