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MONITORING SYSTEM CERTIFICATION For We By Al Jurisdictions 94thin the Spate of California Authority Cited:Chapter 6 7, Health and Safety Code;Chapter 16,Division 3, Title 23, California Code of Regulations This form mustbe 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 ownerloperator. The ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facih�Name: ARCO PRODUCTS COMPANY Service StationNo.: 2133 Site Address: !2908 BENJAMIN HOLT DR City. STOCKTON Zip: 95207 n-: Contact Phone No FaciAty Contact Perso Date of T e sting/S ervic e B. Inventory of Equipment Tested/Certified Check the ffprgpria_Jebones to indicate specific eSu_Vntent!Mected/serviced: TankI Tank ID: Tank Gauging Probe: I Model: __jwik Gauging Probe: Model: arS aceVaiultSensor 1 Model: ar Space or Vault Sensor 1 Model: 'eY46 zkW - _ ----------- T 'D' Tank ID: "k .k in Sump/Trench Sensor(s): I Model: Model: enchSensor(s): 20 ill Su Model: pSensor(s): Model: ill,Su Sensor(s): ------------ e anical Line Leak Detector. Model: $*_*c_o� LeakDetector. Model: ectronic Line Leak Detector Model: I ptkjo ectronic Line Leak Detector Model: ankOvetfill/High-level Sensor: Model. ank Overfill/High- 4evel-sensor: ..-..!....Model: er,Specit[egi;dp.type and model in Section E on Pa e 2 j ther,Specify a ip.!ype and model in Section Eon Pa e 2 . Tank ID: 1 91 Tank ID: 1, n-TankGauging Probe: Model: n-TankGau0nPro e: Model: ace or Vault Sensor: Model: 1 -1' 2,C) nnularSpace or Vault Sensor j Model: M Sum /Trencl,qppenr_Qs Model: i 2-C., i in Sum pgrench Sensor(s) j Model: ixT2Sensor QL Model: illSumpS!nSensor Model: echarucalLineLeakDetector. Model: 'V-0,2 0^2 echanical Line Leak Detector. Model: ctronic Line Leak Detector Model: e ctronic Line Leak Detector Model: gvetfilllHig�i-�evel S e�nsqr: Model: ank Ove!fr�i -levelSensor: Model: Cher,Specify equip.type and model in Section Eon Page 2 tither,Specify equip.type and model in Section Eon Pa e 2 -DI-s-P serTD- user Containment Sensors: Model: -ZOO- enser ContainmentSensor(s):- Model: heir e isp She ar V alve(alveus).isp enser o:�ia�nmer�fkloa a _ enser Containment Float(s)and Chain(s) is Disrser ID: ens er 7-4! enser Containment Sensors: i Model: Z& enser Containment Sens r Model: Zcr D*s en, --------- he ar V She I fD is p enser Containment Floe t(s)and Chain(s) 'NspenserContainmentFloags) and Chs) Dispenser ID: DispenserID: • �s)andChS) ispenser Containment Sensors: Model: ontainment Sensor( isp ens er C deL, ShearValve(s). Shear V alve(s) tenser Containment Float(s) and Chain(s) is enser Containment Float *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at this facility. C Certific ation-I certify that the equipment identified in this document was inspected/serviced in accordance with the m;=ufwftw=' guidelines. Attacked 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 e%uJpnwnt. For any eqyvnwitt capable of generating such reports,I hwe abe attached a c( of the rep history pr�,(check all that qp&):. -x jz%AlarmreAD Technician Name(Print): Signature: 8 At Certification No.: Y�'i�' _i License No.: SIR -10 9 Testing qortip;any Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page I of 3 03101