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MONITOBJNG SYSTEM CERTIFIC ION For U All Jurisdictions Within the State of Califo Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, Title 23, alifornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A seRaarate certification or report must be prepared for each monitorinn 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.: 6347 Site Address: 2430 Joe Pombo Parkway City: Tracy Zip: 95376 Facility Contact Person: � � ►. �_�le-(�-�- Contact Phone No.: ?,y Make/Model of Monitoring System: %L S 3SZ� Date of Testing/Service: B. Inventory of Equipment Tested/Certifl;ed Check the appropriate boxes to indicates ecific equipment ins ectad/serviced: Tank ID: !h Tank ID: []In-Tank Gauging Probe: Model: 01n-Tank Gauging Probe: Model: ,insular Space or Vault Sensor: Model: ( ❑Annular Space or Vault Sensor Model: ping Sump/Trench Sensor(s): Model: ❑Piping Sump/Trench Sensor(s): Model: mill Sump Sensor(s): Model: 2,of- ❑Fill Sump Sensor(s): Model: [3Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: E]ETectronic Line Leak Detector Model:C .2Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank OverfilV igh-level Sensor: Model: ❑Other,SEecj&a ui .type and model in Section E on Page 2 ❑Other,Sgeca equip. e and model in Section E on Page 2 Tank ID: Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: []Annular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: ❑Piping Sump/Trench Sensor(s): Model: ❑Piping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: []Fill Sump Sensor(s): Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: []Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other,S ec' a ui . e and model in Section E on Page 2 ❑Other,S eci a ui . e and model in Section E on Page 2 Dispenser ID: 1 - 2— Dispenser ID: 3---It ®Vispenser.Containment Sensors: Model: 2 (dispenser Containment Sensor(s): Model: i ['Shear Valve(s). shear Valve(s). ❑Dis eraser Containment Floats and Chain(s) ❑Dis eraser Containment Float(s)and Chain(s) Dispenser ID: I'--(p Dispenser ID: -;t-&F- (Dispenser Containment Sensors: Model: 015ispenser Containment Sensor(s): Model: Zvi (hear Valve(s). 2 Shear Valve(s). ❑Dis eraser Containment Floats and Chains ❑Dis enser Containment Floats and Chains FS1hearenser ID: (s). S/y Dispenser ID: /1-/2- spenserContainment Sensors: Model: � enser Containment Senso :r( s): Model:Valvehear Valve(s). E3Disj2enser Containment Floats and Chains ❑Dis enser Containment Floats 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 equi ent. For any equipment capable of generating such reports,1 have also attached a copy of the report;(c eck all that apply): System set-up Alarm histor report Technician Name(Print): L.:. 1*4,e - c,�l� Signature: Certification No.: �SYS License No.: 5WD98 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page 1 of 3 03/01 Monitoring System Certification