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<br />MONITORING SYSTEM CERTIFICATION
<br />For [Jse ByAll Jurisdictions
<br />11"ithill tare 'Wle q1'('01Ybrr11e1
<br />Authorr> Cited: Chiy)ter h.7, Health and.S4kfj' (. wie, Chapter
<br />16, Division 3, 'Tide 3, Cal!ft)rnia ("ode ofReglid(Vionj
<br />1*11is loinn must he used to document testing and servicing ut'llionitoring equipment.
<br />p g e 1"I o� _��Ijjjq
<br />A Sp a -1L) _P L
<br />qu,Lte IMI, -19 �o t
<br />SxSSE .I. by the technician who perlinnis the wort. A copy of this forrn must be provided to the lank system owner/operator. The o%%ner/ope'nuor
<br />_MRV_l
<br />inust subrait a copy ofthis form to the local agcncN regulating (jS,I, syslerris within
<br />3t) daysofte,,,t date,
<br />A. General Information
<br />Facility Name: ARCO AMPM
<br />.. . . . ... ...... Counw SANJOAQUIN
<br />Site Address: 890 E VICTOR RD
<br />Cate LODI
<br />Facilitv Contact Person: {ARAM
<br />Convact Phone 209-369-0958
<br />Make Model ofMonitoring System! TUS350 — - - --------
<br />Date of' T'esting;'Servicinu: 9/23/2014
<br />B. inventory of Equipment 'Fested/Certified
<br />Tank ID: TI -87
<br />Tank ID: T2-911 ...........
<br />0 In.4ank (jailging Probe Model: MAG
<br />N
<br />%-Uldel: IAG
<br />0 Annular Space or Vault Sensor. Model: M
<br />Z Annular Splice or Vault Sensor, klodcl: 301
<br />0 Piping Sullip ; Dench Scrisor(s). Modcl: 208
<br />0 vjpnjg,;urnp %'l reach Senq)rla Model: 208
<br />0 Fill Sump Sensor(s). Model:
<br />Cl Fill Sump Sensor(s), Modcl:
<br />0 Ivlechanical Line Leak Nlecwr, Model: 1,02000
<br />�,lechaj�ical Eiric Leak 1,ktector. ModcL LD2000
<br />0 1:1ectronic Line Leak U)cWtor. Modell
<br />Electronic Line Leak Detector. Model —
<br />STank Overfill i fligh-Level Sensor Nlodel: FLAPPER
<br />I 01'ank Overfil I,, high -Levet Sensor. Model: FL,%PPER
<br />[] other equipmend type and niodel in on F on Page 2),
<br />[] Other I specify equipment type and mode.{ in Sectilin E on Page 2),
<br />(spccjty
<br />TankID: T3 -DSI,
<br />Tank 113:
<br />sill. Tank Gauging Probe. Model: MAG
<br />F1 lo -Tank 6au,ging Probe, ModeF
<br />0 Annular Space or Vault Sensor. Model: 420
<br />Annular Splice on Vault Sells- Model:
<br />ED Piping Sump ,"I'reach Scilsol(s). Model: 208
<br />❑ Piping Sump !french SQnstir(s). model:
<br />0 Fill Sump Sensur(s). Model:
<br />Fill Sump Sellsoqs), model.
<br />Z Mechanical Line Leak Detector. Model: LD2000
<br />mechanical l'ifle Leak Delector Model
<br />E] Electronic Line Leak Dctcctor_ ModeL
<br />❑ Eloctlimio; Linc Leak Detecwt. 710odcl:
<br />01'ank overfill/ High-level Sensor, Model: FLAPPER
<br />[]'Tank Overfill I ligh-Level Sensor. 100jel ......... . . .. . . .......
<br />ge
<br />C1 Other (spceit� equipment type and inodel in Section E oil Pa -2),
<br />j
<br />r 1 Other (+pccif4top: and model in Section t age on P 2),
<br />Dispenser ID: to
<br />Dispenser ID: 314
<br />Conlainnient Sensttr(s). Model: 208
<br />1, jspcjl,,)cr Containmcnt Scnsori Model 208
<br />Shear Valve(s).
<br />Shear vahcw
<br />n Dispenser Contain 111,011( Float(,;) and Chain(s).
<br />n Dispenwr Cimtainnient (Dabs) and
<br />Dispenser ID: ,5/6
<br />Dispenser M 7/8
<br />0 Dispenser Containment Sensor(s), Model: 208
<br />0 Disjwnwr Colitainnicin Sensor(s). Model. 208
<br />0 Shear Valyc(s)�
<br />Shear valve(s).
<br />0 Dispenser Containment Floats) and Chain(s).
<br />El Dispenser Containment Float(s) and Chaill(,O
<br />st
<br />Dispenser ID: 9/to ----------------------
<br />Dispenser ID:
<br />of
<br />Dispenser C�ointainrncnt Scnsor(s). Model: 208
<br />.-P-.' ri
<br />E
<br />Dispenser Containment Sensor(s), Model,
<br />Shear Valve(s).
<br />S
<br />❑ Shear Valve(s),
<br /><.t(,) and:('
<br />0 Di spcnwr Containment Float(s) and Chain(;;).
<br />C] Dispenser Containment Floru(s) and Chatrus 1.
<br />Check the appropriate boxes to indicate specific equipment jospectediserviced;
<br />C. Certification - I certify that the equipment identified in this document was inspected/se ry iced in accordance with the
<br />manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that
<br />this information is correct and a Plan showing the layout of monitoring equipment. For any equipment capable of generatin uch
<br />reports, I have also attached as copy of the report, (check all that apply)- 0 System set-up M Alarm history re
<br />Technician Narne (print): ALEXANDER TATE Signature:
<br />. ........ ..
<br />Certification B42662License No.: 433159
<br />. . ............. . .
<br />'resting Company Name: R. Z. Service Station Maintenance Phone No.: (916) 371 -2380
<br />... .. . .... _ ------
<br />. . . ..... . ..
<br />Site 1041 Triangle Court West Sacramento, C.A 95605 Date ot`Tcsting�'Servicing: 9/23/2014
<br />1 -1 1-1-1.- . 11-111111--, � .. . .......... .... ...
<br />. . . . . ........ ..........
<br />Monitoring Certification Test Report
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