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Jun-25-2002 03:16pm From-ARCO PROD, +714-670-3095 T-919 P.003/006 F-953 0A MONITORING SYSTEM CERTIFICATION For Use By all Iurisclierions Within the Sta:c of CalVornia Authority Cited:Chapter 6.7.Health and Safety Code;Chapter 16,Division 3,27tle 23, Californias Code of Regulations This form must be used to document testing and servicing of monitoring equipmelit.A senaraee Gen(ficatien or report must be prepared for each enitorin system onntroi ane by the technician who performs the work. A copy of this form must be provided to the trunk System owner/operator. The owner/operator must subunit a Copy of this form to the local agency regulating UST Systems within 30 days of test date. A. General Information Facility Name: Bldg.No.:_-_ Site Address: It: City:, Zip: - Facility Contact Person: C.)ntact Phone No.: Make/Model of Monitoring System: ?sate of Testing/Scrvicing: B. znventpry of Equipment Tested/Certified Check the a rP riate boxes to indicate S tie a ui inent 1--peetcd1svryice4: Tank ID: Tank ID:_. Cl In-Tank Gauging Probe, Model: Q In-Tank Gvagins Probe. Model: ❑ Annular Spice or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: _ ❑ Piping Sump/Trench Sensor(s). Model: 13 Piping Sun,p/Trench Sensor(s). Model: Q Fill Sump Senser(s). Model: ❑ Fill Sump::Cnsor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. . Model: ❑ EIcotronic gine Leak Detector. Model: Q Electronic line Leak Detector. Model: ❑ Tank Overfill/High-Level Sensor. Model: !;1 Tank Oven ill/High-Level Sensor. Model: ❑ Other(specify uiament t e and model in Section E on Paste 2). Cl Other{s ui menu Expe and model in Suction E on Pa c 2). Tank M- "Cantu M- 13 In-Tank Gauging Probe. Model: ❑ In-Tank Gsugiug Probe. Model: ❑ Annular Space or vault Sensor. Model: Cl Annular Sp•ece or Vault Sensor, Model: Cl Piping Sump/Trench Sensor(s). Model: ❑ Piping Sun,p/Trench Sensor(s). Model: Q Fill Sump Sensor(s). Model:,^ — U Fill Sump Scnsor(s). Model: --- ❑ Mechanical Lane Leak Detector. Model: ❑ Mechanic3i Line Lank Detector. Model: ❑ Electronic Lane Leak Detector. Model: U Electronic)Ane Leak Det=mr. Model: Cl Tank Overfill/High-level Sensor. Model: C.1 Tank Overl,ll/High-Level Sensor. Model: ❑ Other(sEEla ui ment t c and model in Section E on PuLc 2). ❑ Other(s .f !2ujpment!X2e and model in Section Eon Pae 2). Dispenser M. Dispenser M-. M~ ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser(ontainment Senkor(s). Model: 2f Shear Valve(s). ecLshear Vaiv,(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser(onwinment Float(s)and Chain(s). Dispenser ID: Dispenser W: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser(ontainment Sensor(s). Mode): ❑ Sheur Valm(s). Cl Shear Valy.(s). ❑ Dispenser Containment l:loa0s)send Chain(4. ❑ Dis enser(ontalnmertt Float(s)and Chain(s). Dispenser ID: Dispenser 10: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser(ontaitunent Sensor(s). Model: ❑ Shear Valve(s), O Shear Valw(s), QDis enser Containmcnt Floats)and-Chain(s). ❑ Dis nser Containment Float(s)and Chain(s). *if the facility contains more tanks or dispensers,copy this form. Include information for a eery tank and dispenser at the facility. C. Certification-I certify that the equipment identified in this document was inr+pected/serviced in accordance with the manufacturers' guidellnim Attaehed to this Certificadon is infortnation (e.g. manufacturers' checklists) neemary to verify that this Informadou is correct and n Plot Plan showing the layout or monitoring equipment- For any eq,Lipment capable gen such reports,I have also attached a copy of the report;(check all that apply): Q System set-up L 1 ep , Technician Name(print): Mai, n =CQ30-i*y Signature:s Certification No.. License.No. Testing Company Name- Scott CQ- Qf 0A.1 i fnrn a Phone No.:( 51(l 895-2333 X 3$5- Site Addreas- Datc of Testing/Serviaing: Page i of 3 03MI Monitoring System Cerd ication