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MONITORING SYSTEM CE!at'�of IF TION Fo, - By All Jurisdictions Within the SCa Authority Cited: Chapter 6.7, Het d Safety Code; Chapter 16, Division 3, Titl "'alifornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must 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 Facility Name: ARCO PRODUCTS COMPANY Site Address: 3212 N. California Service Station No.: 2186 City: Stockton Facility Contact Person: = �� S�&_ Contact Phone No Zip: 95204 Make/Model of Monitoring System: —7—z5 3-s-0 Date of Testing/Service: �(j-►��y3 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: A17 Tank ID: Q ❑In -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: jEq?cffnular Space or Vault Sensor: Model: p 2nnular Space or Vault Sensor Model: tping Sump/Trench Sensor (s): Model: iping Sump/Trench Sensor (s): Model: L ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: laElectronic Line Leak Detector Model: DETectronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, Specify equip. a and model in Section E on Page 2 ❑Other, Specify equi2. jMe and model in Section E on Pa e 2 Tank ID: Tank ID: ❑In -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: ❑Annular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: [-]Piping Sump/'Trench Sensor (s): Model: []Piping Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, SEecify aqui a and model in Section E on Page 2 ❑Other, S2eciLy equip. a and model in Section E on Page 2 Dis eraser ID: 1-2— Dispenser ID: Rs enser Containment Sensors: Model: 7oa- Elbispenser Containment Sensor(s): Model: hear Valve(s). 2.1h'ear Valve(s). [-]Dispenser Containment Float(s) and Chain(s) ❑Dis eraser Containment Float(s) and Chain(s) Dis e er ID: r- Dispenser ID: T- enser Containment Sensors: Model: �ispenser Containment Sensor(s): Model: Shear Valve(s). 2-Sfear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) ❑Dis enser Containment Float(s) and Chain(s) Dispenser ID: Dispenser ID: [-]Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s) ❑Dis enser 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. C. Certification - 1 certify that the equipment identified in this document was inspected/serviced in accordance with 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 equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that applv): ❑ System set-up ❑ Alarm history •eport Technician Name (Print): /C"; - L)z,CA Signature: Certification No.: /3s_o License No.: 58805-8 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222 Page 1 of 3 03/01 Monitoring System Certification