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MONITONG SYSTEM CERTIFIC TION For U . All Jurisdictions Within the State of Califo; Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California 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 Service Station No.: 6080 Site Address: 85 E. Louise Avenue City: Lathrop Zip: 95330 Facility Contact Person: --Xc,k,, SContact Phone No.: 2-Q Q ��- 1`9- 5— Make/Model Make/Model of Monitoring System: -7-2 S 3Date of Testing/Service:1/O-/�,�v B. Inventory of Equipment Tested/Certified Check the aEEropriate boxes to indicate sl2ecific a ui ment ins ected/serviced: Tank ID: ctc=0 Tank ID: F ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: annular Space or Vault Sensor: Model: 3bz annular Space or Vault Sensor Model: 3�0z 4P 2iping Sump/Trench Sensor(s): Model: (wiping Sump/Trench Sensor(s): Model: zr� ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: [ 3jMechanical Line Leak Detector. Model: 4pzn,,D Mechanical Line Leak Detector. Model: L ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, Specify egui2. IMe and model in Section E on Page 2 ❑Other, SEecify a ui a and model in Section E on Page 2 Tank ID: 1;1Tank ID: ❑ln-Tank Gauging Probe: Model: [31n-Tank Gauging Probe: Model: J2<mular Space or Vault Sensor: Model: Sul iW ❑Annular Space or Vault Sensor Model: C PKping Sump/Trench Sensor(s): Model: Za•,P- ❑Piping Sump/Trench Sensor(s): Model: []Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: EMechanical Line Leak Detector. Model:"2e,c.J [-]Mechanical Line Leak Dete I ctor. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level S�nsor: Model: ❑Other, S eci aqui a and model in Section E on Page 2 ❑Other, Specify equip. a and model in Section E on Page 2 Dispenser ID: — Dispenser ID: 3—% 1( �spenser Containment Sensors: Model: 20 Cis enser Containment Sensor(s): Model: Za 2-51iear Valve(s). p ear Valve(s). []Dispenser Containment Float(s)and Chain(s) ❑Dis enser Containment Float(s) and Chain(s) Dispenser ID: S Dispenser ID: 2116, enser Containment Sensors: Model: ( penser Containment Se or(s): Model: Z Shear Valve(s). Shear 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 Sesor(s): Model: ❑ Shear Valve(s). E] Shear Valve(s). ❑Dis enser 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 - 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 Piet Plan showing the layout of monitoring equip t. For any eq��uipmme t capable of generating such reports,I have also attached a copy of the report; (ch ck all that apply): ystem set-up C3'-Alarm history eport Technician Name(Print): fie,,2,, -___,:�-,A c-� Signature: i Certification No.: /-3 License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222 Page 1 of 3 03/01 Monitoring System Certification