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Dec 11 02 05:49p —qIT Environmental System r"1.6) 858-1011 p.6 MONITORING SYSTEM CERTIFICATION 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 Corte 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 Service Station No.: 2186 Site Address: 3212 N. California City: Stockton Facility Contact Person: jjft,)UL;' `�tF- • t�Af� Contact Phone No.: Gip: 95204 Make/Model of Monitoring System -V- R obT 7LS 3 5 Com/ Rte- C'�[ Date of Testing/Service: f B. Inventory of Equipment Tested/Certified � Check the annronriate boxes to indicate specific eauiorttent insaected/serviced: Tank ID: - - t> Tank ID: -- _ ❑In -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: $]Annular Space or Vault Sensor: Model: O gAnnular Space or Vault Sensor Model: -%O ®Piping Sump/Trench Sensor (s): Model: 0 $ [RPiping Sump/Trench Sensor (s): Model: _o.2e ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: []Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: NElectronic Line Leak Detector Model: L v )]Electronic Line Leak Detector Model: A 742-f ❑Tank Overfrll,4 igh-level Sensor: Model: []Tank Overfrll/lligh-level Sensor: Model: ❑Other, Specify equip. t e and model in Section E on Page 2 ❑Other, Specify equip. e and model in Section E on Page 2 Tank ID: c' — 10k, Tank ID: ❑In -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: Wrinular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: J RPiping Sump/Trench Sensor (s): Model: []Piping Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: [Will Sump Sensor (s): Modcl: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: NElectronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: OTank Overfill/High-level Sensor: Model: ❑Tank Overfrll(High-level Sensor: Model: ❑Other, Specify a ui . e and model in Section E on Pa e 2 ❑Other, Specify a ui . e and model in Section E on Pape 2 Dispenser ID: j/z Dispenser ID: %zn WDispenser ContainmeAtt-Sensors: Model: &Dispenser Containment ensor(s): Model: v ' ❑ Shear Valve(s). ❑ Shear Valve.(s)_ ❑Dis enser Containment Float(s) and Chain(s) ❑Dis enser Containment Float(s) and Chain(s) Dispenser 1D: J'& Dispenser ID: Dispenser Containment Sensors: Model: 3L p 1K ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chains []Dispenser Containment Floats and Chain(s) Dispenser ID: Dispenser ID. JSDispenser Containmen Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s) and Chains ❑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 - I 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 apply): ❑ System set-up ❑ Alarm history report NO -e F-' 1 iJ i i.r- TechnicianName(Print): DRN&Ar� ftSIC_ Signature. Certification No.: ©DC cv, as" -4 License No.: 588 09 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: 714) 560-8222 Page 1 of 3 03101 Mouiloring System Certification