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MONUORING SYSTEM CERTIFICATION For Use$y All Jurisdictions A3thin the State of California Authority Cited: Chapter 6.7,Health and Sgfety Code;Chapter 16,Division 3, 27He 23, California Code of.%Rulatr'ons This form must be used to document testing and servicing of moritoringequipment.A separate certification orrenortmust 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 FaaldyName: ARCO PRODUCTS COMPANY ` service Station No : ,`9600 --- SiteAddress: 1250 N WILSON WAY i Crty: STOCKTONZip .,:95202 FacrhtyCortapferson: ContactPhoneNo.: M,& odeIOfMonrtorin S stem -_•---- - .-- -_ --_-.--� y—_ V 2 7[S � SY-7 _Date oPToo tin p,/Servrca:. � be B. Inventory of Equipment Tested/Certified Check the wprupriate,boxes to indicate ecdfie e . meat' ected/serviced: Tank ID: Tank ID: Tanlc_OaugmgProbe: Model: an _ging Probe: Model: _Space or Vault Sensor_ ; Modek 1 oraceordaultSensor ModeL z SwapllxenchSensor(s)_ Model: ; 2c,5-- 1 Model: ee. --- SeasorOi_.. ._-- -_-Model: 1acs __SumpSensor(s):., __ ModeL eoY echnc»cdLine Leak Detector. %ModeL [o eehanicalL.neLeakDeteetor. Model: ckorncLirteUea b teetor_ ...j Model: I ectronicUi eLeakDetector 1 Model: --- _ _. Ete.ne.. erfilllHigh-levelSensor: ' Model. ankOvemll/High-level Sensor: ModeL S ec' a ui .Me and model in Section E on Page 2 ther.Specifyquip.type end model in Section E n.Pa e2 Tank ID: fp 9 ID: Tack Probe: I Model fiUS kCiaug�gn ProbeModeL erSpaceorVaultSensor: Model: ; � 2. arSSaceorVaultSensori Model:Su �ffrenchSensor e : ModeL 1S�gr1chSensor _ _ 1 Model:ensor e : ModeL• Sensor aModeLechenicalLineLookDetector. Model: 1a4(&o nicalLineLookDetector. Model:ectrorriclineLeekDetector Model: nicLiaeLeakDeteetor ModeLenkc ve:fill/fiipi•IevelSensar: 7Modet_ __ ve -level Sensor: ModeLTher S ec' a .t o and model in Section E on P e tSec' a type and model in Section E on P e t —e Dispa ser ID: S-� i erCmrtaviment5eneore;_ Modal: — 3�z _ r f eneerConteinmeintSenso; s# ode): ?S hear V alvees . 1 ._.. hear Valy_a(s), enserContainmentFloa s and Ch ' s i enserContainmentFloes and Chi'gKs erserID: -lb Dis enserID_ 93-/ erCantmnmertSensors: Model: - - -- - T�— - - Se ( : Model: h rVolveeefValve() ienserConteinmentFloaand Ch up hanearCantamentFloe sandChais S Dis enserlDspanserlD: neerCanteinmentSensors: ode): s rspem.rContammentSensor(s): Model: hear Valve(s) Sheer Valve(s). is enserContainment Flo! $ and Chem(?) Dis eaget Cant einmentFloes and Ch ' 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 chat the equipment identified in this document was inspected/serviced in accordance with the manufacdora' guidelines. Attached to this Certification is infornation(e4 manufacturers'checklists)necessary to verify that this information is cosset and a Plot Plan shaving the layout of manitoung meat For any eolliant capable of generating such reports,I haeales attached a copy of the report; (check old tkat_ p _ .....p��Ystem set vp_ .l laxm history raggr l �t Techttician Name(Print): C,*eAs� - t=om ock. Srgneture' ( � yt a CertsfieetionNo: /3s(o License No.; 9R Tedd _ompanyName TAIT EUVIRANMENTALSYSTEMS Phone No.: ()14)560.8222 Page 1 of 3 83101