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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the Slate of California Authority Cited:Chapter 67, Health and Safety Code;Chapter 16,Division 3, Title 23, California Code gfReglahom This form mustbe usedto documenttesting and servicing of monitoring equipment.A separate certification orrenortmustbe prepared for each monitoring system control panel by the techniciah'who performs the work. A copy of this form must be provided to the tank system owner/operator. The ownerloperator must submit, a copy of this form to the local agency regulating UST systems within 30 days of test date. A General Information _ Faci4tyName: I ARCO PRODUCTS COMPANY _1 Service Station No.: 16100 .w j Site Address: 25775 S PATTERSON PASS ! Cj TRACY I Zip: X95376 1 Facility Contact Person: �' , � —'}p, Contact Phone N o.:� Mn�lce/ModelafMonstoringSystem: — - ►J �ZS .�07�jS Date of Testing/Service: --3 1 B. Inventory of Equipment Tested/Certified Check the aWpiVriate boxes to imdicatt Specific a roentectedlservioed: Tank ID: 's Tank ID: -e— Ui=nkOvedill/High-levelSe au ' Probe: Model: ' 7 9b/ enkGau Probe: Model: 3 /a pace or Vault Sensor: Model: alar space or Vault Sensor Model: 9 renchSensor�: Model: Sump/Trench Sensor(a): Model: ? y Sensor s : I Model: 9 ill SumpSensor(s): Model: elLineLenkDetector. Model: echanicnlL.ineLenkDetector. Model Line Leak Detector Model ctronic Line Leak Detector_ ! Model lc nsor: Mott;; , c,o5Z-vo/ ankOverfill/Hi -levelSensor: Model: ca,Sp, equip.t e and model in Section E on P ' e 2 Itther,§2ecfy a ui .t e and model in Section E an Page 2 Tank ID: 5 a Tank ID: 9 n-Tnnkt3augngProbe, _ Model ,� Tank Gou ' Probe: _ _ _� Model: 7 94)A7 nnutnrSQace or VaultS_ensor: ; Model: 4 nnularSpace or Vault Sensor Model: ' 9 1 . gSump/TrenchSens or 5 Model: ?y �i 1 ' gSL= /Trench Sensor(sZ_ Model: � ills Sensors Model 9 ally Sensor(s): ;_Model: ?9 1a echanicalLine Leak Detector. Model a nrlical Line Leak Detector. Model ctronic Line Leak Detector Model ectronic Line Leak Detector Model: ankOverfyll/H' level Sensor: Model 0/ nnkOve •level Sensor. Model c�yS-to/ r,S eci e e and model in Section Eon Pe e2 at,Spec' e .t e and model in Section Eon P e 2 Dispenser ID: Du enser ID: Emu-Am I enserContainment Sensors: j Model: V' s enserContainmentSenso a : Model ear Valves . ! j ear Valvas . j _ is enser Containment Flon s and Ch ' s s enser Containment Fla s and Ch ' s Die censer ID: neer ID: ewer Containment Sensors: ; Model: 4J,41 enserCoentSenso s : V Model: ShearValve(s�_ ShaarL; 2CL is cnser Containment Fla sand Ch s erant Flo s andCh ' s Dis onset ID: dWz&Peraser ID: is ewer Containment Sensors: j Model: ponser Containment Sensot(s): ; Model Shearvaly s . She _ 1 _ arvalve(e). I _` enserContainmentFlo s and Ch ' s T ens orConteinment.Fla a 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. C ertific ation-I certify that the equipment identified in this docu xt was inspectedherviced in accordance with the numxficbh ' guideline:. Attached to this Certification is iniorna#ioh(e.r, manufictvren'checldisis)necessary to verify that this tnfermatior►is correct ani a Plot Plan showing the layout of msniissiu j equijpdat For any eq��at capable of Cementing such reports'I lou sho attached a copy of the_rgori;(check all that apply): _.p'S�stex set-up eAlarm histo rmwrt TechrricianNnme rent & Z.�C.f TSignnture: — -)--- "1 ------ Cottifrcation No.: _ 4V 7 C/ 1 License No.: Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (71�560-8222 Page 1 of 3 03101