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r MONARING 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.: 9600 Site Address: 1250 N WILSON WAY City: STOCKTON Zip: 95202 Facility Contact Person: �,T 0k r, Contact Phone No.: Make/Model of Monitoring System: 5fO Date of Testing/Service: /p-(FL ?1L- B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: Tank ID: [$In-Tank Gauging Probe: Model: 41 S9 0 1 o In-Tank Gauging Probe: Model: MAnnular Space or Vault Sensor: Model: ')S i9"-14 Annular Space or Vault Sensor Model: "t 12 ®Piping Sump/Trench Sensor(s): Model: 3d - Piping Sump/Trench Sensor(s): Model: --j Qn -Lore [flFill Sump Sensor(s): Model: lg Ivo- mFill Sump Sensor(s): Model: fp-lo []Mechanical Line Leak Detector. Model: ( ❑Mechanical Line Leak Detector. Model: L49j CL"o� ❑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. a and model in Section E on Pae 2 ❑Other,Specify equip. e and model in Section E on Pae 2 Tank ID: R Tank ID: Tin-Tank Gauging Probe: Model: %o- Ie ❑In-Tank Gauging Probe: Model: IOAnnular Space or Vault Sensor: Model: 7 j kt 7.r&,o— []Annular Space or Vault Sensor Model: EgPiping Sump/Trench Sensor(s): Model: 'Iti3 h ❑Piping Sump/Trench Sensor(s): Model: ]Fill Sump Sensor(s): Model: 9k 3¢o • )-a []Fill Sump Sensor(s): Model: []Mechanical Line Leak Detector. Model: J-dap ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: []Electronic Line Leak Detector Model: []Tank Overfill/High-level Sensor: Model: ❑Talk Overfill/High-level Sensor: Model: ❑Other,S eci equip. a and model in Section E on Pae 2 ❑Other,Specify equip. e and model in Section E on Pae 2 Dispenser ID: t -t- Dispenser ID: 7^-& $Dispenser Containment Sensors: Model `79 39o-Al InDispenser Containment Sensor(s): Model:7 f't j FO-3f- UL Shear Valve(s). to Shear Valve(s). []Dispenser Containment Floats and Chain(s) ❑Dis enser Containment Floats and Chain(s) Dispenser ID: I-`( Dispenser ID: 7-" Dispenser Containment Sensors: Model: 71`1316 ODispenser Containment Sensor(s): Model: 7443 Shear Valve(s). [Z Shear Valve(s). []Dispenser Containment Float(s)andChains) ❑Dis enser Containment Floats and Chain(s) Dispenser ID: Dispenser ID: #-/ PDispenser Containment Sensors: Model: 714jj0,7Lj ZDispenser Containment Sensor(s): Model: -11043117-3(1 [t] Shear Valve(s). [2t Shear Valve(s). []Dispenser Containment Floats and Chains) ❑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,I have also attached a copy of the report;(chec all that apply): Iia System set-up Alarm histor r port Technician Name(Print): pa-W Signature: Certification No.: j Y;1(If License No.: 588098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page 1 of 3 03101 Monitoring System Certification