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r MONIMNG SYSTEM CERTIFOATION For Use By All Jurisdictions Within the State of California 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.: 6335 Site Address: 4855 South State Route 99 City: Stockton Zip: 95215 Facility Contact Person: ,o H AJ SH C T - 2 Contact Phone No.: Make/Model of Monitoring System: -rL-S - 35'c) Date of Testing/Service: 3 2 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: $-7 Tank ID: []In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: lar Space or Vault Sensor: Model: 7 fY39b p ular Space or Vault Sensor Model: 79 90-r/D iping Sump/Trench Sensor(s): Model: 79Y3 ga-? ,g ipmg Sump/Trench Sensor(s): Model: -7 9 fv3 9b 20 []Fill Sump Sensor(s): Model: ❑F311-Sump Sensor(s): Model: ❑.N*hanical Line Leak Detector. Model: Ci K4echanical Line Leak Detector. Model: t A - Z r c FVKlectronic Line Leak Detector Model: C- ❑Electronic Line Leak Detector Model: []Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other,Specify equip. e and model in Section E on Pae 2 ❑Other,Specify equip. e and model in Section E on Pae 2 Tank ID: Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: alar Space or Vault Sensor: Model: 794 �Tt-4D ❑Annular Space or Vault Sensor Model: ipm Sump/Trench Sensor(s): Model: 7 94 35a-2o ❑Piping Sump/Trench Sensor(s): Model: ❑F. Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: echanical Line Leak Detector. Model: 4 - c ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: []Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other,Specify equip. e and model in Section E on Page 2 ❑Other,Specify equip. e and model in Section E on Pae 2 Disp er ID: Z Dis enser ID: Spenser Containment Sensors: Model: 79V;tF -z�9 2}�penser Containment Sensor(s): Model: g! Shea - Shear Valve(s). L.-YShear Valve(s). ❑Dis enser Containment Float s)and Chains ❑Dis enser Containment Float(s)and Chain(s) Dis$�nser ID: �' (o Dis user ID: `7 [ i enser Containment Sensors: Model: �y +• c$ [ enser Containment Sensor(s): Model: hear Valve(s). Shear Valve(s). []Dispenser Containment Float(s)and Chains ❑Dis enser Containment Float(s)and Chain(s) Dispenser ID: t/7 Dispenser ID: // / Z. ispenser Containment Sensors: fodel: 7j E4ilspenser Containment Sensor(s): Model: - ®Shear Valve(s). VShear Valve(s). ❑Dis enser Containment Floats and Chain(s) ❑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 equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(ctlC�k alt that apply): System set-up r(Alarm history ree�ff rt�� Technician Name(Print): ��/ /nYc ve Signature: Certification No.: 4,(/-/?3a License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page 1 of 3 03/01 Monitoring System Certification