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-5 Vj MONII -RING SYSTEM CERTIFIC - TION For Use Bv.4/1 Jurisdictions Within the rlulhority Cited: Chapter• 6.7, Henllh anal Wei)) Code; Chapter 16 DiP#NzAlia , G��r Code of Regulations This form must be used to document testing and servicing of monitoring equipment. Aseparate certification or report must be prepared for each monitoring system control p sl by fhe technician who perfonnFERwrl R09y of this form must be provided to the.tank system owner/operator. The owner/operator must submit a copy of this form to the ocal agency regulating UST systems within 30 days of test date. ENVIRONME11T HEALTH A. General Information PERMIT/SERVICES Facility Name: ARCO ALDm Bldg. No.054 )39 Site Address:City:`( 14- }~> Zip: q'5 2—Qj Facility Contact Person: 1_'au'7 4'_A'Cf , Contact Phone No.: Make/Model of Monitoring System:\,/r(Pdey, Z3t4 -T 1.5. 360 Date of Testing/Servicing: _ _/9 C) /09 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates eci(ic ec ui icnt inspected/serviced: Tank ID: TankID- g'� SIG-jcC In -Tank Gauging Probe. Model: r-1}t=i{� g_ n -Tank Gauging Probe. Model: P—IR nular Space or Vault Sensor. Model y 0 7Annular J�7 Space or Vault Sensor. Model: 7 Piping Sump / Trench Sensor(s). Model: " ! r Piping Sump / Trench Sensor(s). Model: ?_?, Fill Sump Sensor(s). Model: 2 ,12fFill Sump Sensor(s). Model: 3 2 3 ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: C�'�lectronic Line Leak Detector. Model: Ll— Electronic Line Leak Detector. Model: L7 Tank Overfill /High -Level Sensor. Model: q D �o C,Kank Overfill / High -Level Sensor. Model: �o ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment t e and model in Section E on Pae 2). Tank ID: '11 Tank ID: In -Tank Gauging Probe. Model: IVB( �_ ❑ In -Tank Gauging Probe. Model: C�4tuwlar Space or Vault Sensor. Model: t/t)-7 ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 37 ?, ❑ Piping Sump / Trench Sensor(s). Model: Ld'Fill Sump Sensor(s). Model: 3 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: PLOO ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: 10 7t2 ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). Ll Other (s eci a ui ment type and model in Section E on Page 2). Dispenser ID: 3 -- Di enser ID: 3 �t Dispenser Containment Sensor(s). Model:3ff Dispenser Containment Sensor(s). Model: 3 Z3 ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). DiOenser 1D: 5 Dispenser ID: --7 4 [j ,U Dispenser Containment Sensor(s). Model: ')ispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form. IDClUde information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordancewith 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 equipmen . For any equipment capable of generating such reports, I have also attached a copy of the report; (check a/1 that apps,): ❑ Sy em set-up ory repor Technician Name (print): Felix Ramirez Signature: Certification No.: j� � fo License. No.: OTTL # 08-1740 ICC# 3934 -UT Testing Company Name: A7R- o -P 1b -In ��"T� Phone No.:( ?,.0 ) -7 L4 Ld Q I 1 7 Site Address: _`� to 2-1�R� Date of Testing/Servicing.Q /2/99 9' Page I of'3 03/01 Monitoring System Certification A Results of Testing/Servicing