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MONITORING SYSTEM CERTIFICATION For Use by All Jurisdictions Within the Sate of California Authoribr Cited: Chapter 6.7, Health and ScAfy Code; Chapter 16, Division 3, title 23, California Code of Regulatiom ;'.pis form mustba usedte document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitorine ;system control genet by the technician who performs the work. A copy of this form must be provided to the tank system ownedoperator. The ownerloperetor must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information .Faci_Name: 'ARCO PRODUCTS COMPANY _— ^-_I Service StationNo.7_�2186 Site Address: '-3212 N CALIFORNIA City: STOCKTON95204 Factlit Contact Person _ ,�� _--- - — - Contact Phone No.: Make/Model ofMonitorin System ' - 3507 1 Date ofTestinaervice: I/of/ S. Inventory of Equipment Tested/Certified Ckeck the opproptiate tierces to ixdicate ifle a =ext inspeeiedlseniced: Tank1D: $i TenkID: "] -TankGaug�Probe: Model TankGau�Probe: ; Model: � m,- J _ _', ArmulerSpace or VaultSensar ; Model: rmularSpace or Vault Sensor Model: -7q'jrD-4V? Sura_p/Trench. Sens orsss : Model iaSurnpSeneor s_ Models -7;'c echanical Line Leak Detector. ! Model: I in Sump/TrenchSensor (s): !Model: ,� "}?43 g illSump_Sensor(s)_ I Model- echanical Line Leak Detector. Model. , ctronic Line Leak Detector Model: ectronic Line Leak Detector Model: --- -- TankOverfill/High-levelSensor: yModel: '`cs�T!_ — ankOverfill/High-levelSensor: Model_ (-CUI the; S ec" a . t a and model in Section E on P Tank -D: j Re e t er S ec' a L e and model in Section E on P e 2 TanklD: TankGaugingProbe: _ Model n-TankGau ' Probe: � Modell' rsnuiatSpaceorVaultSensor: Model: AnnularSpaceorVaultSensor !_Model:_ inS grenchSansor s ^ ; Model: I ��t3Ts�- il1S Sensor s_— Model: echenicalLine Leak Detecto_r._ r Model: gSump/TrenchSensorSso_:^_ Model: illS Sensor(s): J Model: echanical Line Leak Detector. Model: eetronic Line Leak Detector Model: ectronic Line Leak Detector ; Model: , _ _ TankOverfsil/Hi -levelSensor: ModeL ;L`3C 71__07 ankOverfilUl�igh-levelSensor: _M_ odel:-' _ e Sec' a . t a end model in Section E on P e t er S ec a . t a and model in Section E on Page 2 erID: 2 Dis enser ID:enserConteinmentSensars: ;Model: enserContainmentSensor(hearValve(s). lens Shear Valves . ------ - enser Containment Flo n s end Ch ' s enser Containment Floa s and Ch ' s enser ID: ContairunentSensors: .Model "�)ciq enserContairunentSesisor(SheatValve(s) V�p'vens'er ' Containment Flo a s and Ch ' s ger ID: Dispenser Containment Flo s and Ch s _Dis censer ID: _ ; enser Containment Sensors: Model: 1?�� i enser Containment Sens o s : Mo dei_� rvalve shearenser Containment Flo s and Ch " s ens er C ontainment Floa s and Ch ' s 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 equtment identified in this docur entwas inspected/senvked in accordame with the manu5ifim n' guWliaes. Attached lo tkis Certification is information (e.g. Manufacturers' checklists) necessary to verify that this information is corood and a Plot Plan showing the layout of monitoring egm#xwnt For anyquipment capable of generating such reports, I hatesho attached a copyf the o heck all that apply): item set- Aluvt kisio ort _ — TechnicianNome riot . i ature: CertificationN_c i I License No.: 59� ; T e sting C omp any Name: ; TAIT ENVIRONMENTAL SYSTEMS Phone No.: (7 14) 360-8222 Pare 1 of 3 03191