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MONITORING SYSTEM CERTIFICtION 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 n or rr This form must be used to document testing and servicing of monitoring equipment.A separat`ftcaho or re must be prepared monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the w1m for ea � The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 system owner/operator. days of test date. A. General Information Service Station No.: 9600 Facility Name: ARCO PRODUCTS COMPANY Site Address: 1250 N.Wilson Wa City: Stockton Zip: 9520_ D Contact Phone No.: Zv" �qq -3 3 3�S��o3 Facility Contact Person: l ��"� SG� `"' ' L V _j �� Date of Testing/Service: Make/Model of Monitoring System: i rrrii trry B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicate s ecific a ui ment ins ectaendk/seerrviced: TTa ID: �In-Tank Gauging Probe: Model: TankGauging Probe: Model: / Annular Space or Vault Sensor Model: Annular Space or Vault Sensor: Model: C Piping Sump/Ttench Sensor(s): Model: Piping Sump/Trench Sensor(s): Model: Fill Sump Sensor(s): Model: 4 Fill Sump Sensor(s): Model: `79 71J5 (� Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: t Electronic Line Leak Detector Model: []Electronic Line Leak Detector Model: ip Tank Overfill/IIigh-level Sensor: Model:CYGY-Sb-G'0 Tank Overfill/Hi Sensor: Model: Q�i�' I ❑Other, S eci a ui a and model in Section E on Pagel_ ❑ ID: S ecify a ui a and model in Section E on Page 2 Tank Tank ID: ❑In-Tank Gauging Probe: Model: In-Tank Gauging Probe: Model: Annular Space or Vault Sensor: Model: []Annular Space or Vault Sensor Model: /Trench Sensor(s): Model: ❑Piping Sump/Trench Sensor(s): Model: Piping Sump []Fill Sump Sensor(s): Model: Fill Sump Sensor(s): Model:`M O viechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ,1Tank Overfill/High-level Sensor: Model: (�G X�7S�-L/10 []Tank Over fill/High-level Sensor: Model: [']Other, S eci a ui . e and model in Section E on Pa e 2 []Other,S a ui a and model in Section E on Pae 2 . Dispenser ID )O I Dispenser ID: is enser Containment Sensor(s): Model:?343�U- Z Dispenser Containment Sensors: Model: t hear Va ). ��11 Shear Valve(s). ❑Dis enser Containment Float s)and Chain(s) ❑Dis enser Containment Floats and Chains Dispenser I /y / Dispenser ID: Dis ensetainment Sensor s): Model: .j KIDispenser Containment Sensors: Model: i Shear Va ). [� Shear Valve(s). ❑Dis ensetainment Float(s and Chain s (]Dis enser Contaitunent Floats and Chain(s) Dispenser It:7(91 L52o Dispenser ID: #Dispensetainment ens r(s): Model: 4 3Li Dispenser Containment Sensors: Model: Shear V ). JA Shear Valve(s). ❑Dis ensetainment Float s)and Chain s) []Dispenser 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. ance the C guidelines.atAttached toify th shat the equipment Certifi Certification is informatiotified n(e.g. moanufacturers'inspected/serviced checklists) necessary torve verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. Vry� System set-up y equipment 4Alarm history treport attached reports,I have also attached a copy of the report;(chec"l that pply): "t' y Signature: Technician Name(Print): License No.: 588 098 Certification No.: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-822 Testing Company Name: 03/01 Page 1 of 3 Monitoring System Certification