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MONIT&NG SYSTEM CERTIFIATION 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: ARCH ARCO A1Ig ZPAl Bldg.No.: Site Address: Y$r5- S. M,�y 94 City: —1 TVC-tLT0-✓ Zip: Facility Contact Person: Contact Phone No.: ( ) Make/Model of Monitoring System: lreeaer Roof TLS 35-0 Date of Testing/Servicing: II/fro ? B. Inventory of Equipment Tested/Certified Check the*DDroDriate boxes to indicates ecific equipment inspected/serviced. . Tank ID: T'1 5'? Tank ID: T -2 99 S In-Tank Gauging Probe. Model: v r o 7 id In-Tank Gauging Probe. Model: ✓R Io7 (31 Annular Space or Vault Sensor. Model: vA Yo? 0 Annular Space or.Vault Sensor. Model: ✓R • Yore © Piping Sump/Trench Sensor(s). Model' o e 703 19 Piping Sump/Trench Sensor(s). Model: V R 7& .9 Q Fill Sump Sensor(s). Model: ✓a 1e3 C*Fill Sump Sensor(s). Model: ✓ R 363 0 Mechanical Line Leak Detector. Model: -Mechanical Line Leak Detector. Model: V A4T 40 2 nog 51 Electronic Line Leak Detector. Model: Red .TAc/c� T O Electronic Line Leak Detector. Model: B Tank Overfill/High-Level Sensor. Model: p r 0 A e- 19 Tank Overfill/High-Level Sensor. Model: P roae3 0 Other(specify equipment type and model in Section E on Pae 2 . 0 Other(specify equipment a and model.in Section E on Pa e2 . Tank ID: -r, 3 9/ Tank ID: JCL In-Tank Gauging Probe. Model: V- W.Annular Space or Vault Sensor. Model: ✓R V o 4 0 Annular Space or Vault Sensor. Model: a Piping Sump/Trench Sensor(s). Model: 3 6 1 0 Piping Sump/Trench Sensor(s). Model: 9- Sump Sensor(s). Model: ,!2 3 6 3 0 Fill Sump Sensor(s). Model: Jgl-Mechanical Line Leak Detector, Model: VNt2 9c' 2-cu,_ 0 Mechanical Line Leak Detector. Model: Q Model:_ - __" G_"E,actronic Line Leak Pet&'RM --'Nodel: U Tank Overfill/High-Level Sensor. Model• . O Tank Overfill/High-Level Sensor. Model: 0 Other(specify equipment a and model in Section E on Pae 2). EO s(specify equipment a and model in Section E on Pae 2). Dispenser ID: H er ID: "tp a,Dispenser Containment Se sor(s). Model: 5A 363 nser Containment Sensor(s). Model: W Shear Valve(s). Valve(s). 0 Dispenser Containment Float(s)and Chain(s). nser Conta nment Floats and Chains . Dispenser ID: r ID:0 Dispenser Containment Sensor(s). Model: nser Containment Sensor(s). Model:0 Shear Valve(s). Valve(s). 0 Dis enser Containment Floats and Chains . nser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). QDiS enser Containment Floats and Chain (s). 0 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 the 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; (check all that apply): S System set-up aAlarm history yreport Technician Name(print): r5. 'Q rocu r%) Signature: d I Certification No.: CC Z SZs 705'e - Vr- License.No.:_433159 Testing Company Name:_B.Z. Service Station Maintenance Phone No.:(_916_)_371-2380 Site Address: 630 Houston Street W. Sacramento,CA 95691 Date of Testing/Servicing: Page 1 of 3 03/01 Monitoring System Certification