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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Wthin the State of California Althority Cited: Chapter d 7, Health and Safety Code;Chapter 15,Division 3, Title 23, Cal;'fornix Code ofRegulahons 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 ownerloperator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information FacilityNarne: s ARCO PRODUCTS COMPANY ! Service Station go.: ;6100 Site Address: i25775 S PATTERSON PASS ! City—" TRACY Y Zip_ 95376 Facility Contact Person: 7 ©�ih — ��e �� y ContactPhoneNo.: meq_ (� V1—.3335` i IUlakelModel oflvIonitorxn System: jun /e S 35-V �u5 1 Date of Teqjnoervice_ B. Inventory of Equipment Tested/Certified Check the gpropriate boxes to indicate specific a ment' ectedlserviced: T ID: 7 /ta.— T ank ID.: 7 trr c -c En- GauginProbe_ Model: '/vla .% ankGau�ingProbe- — � Model: /►1 arS ace or Vault Sensor: Model: i anular pace or Vault Sensor Model_ �T SumpfTrenchSensor(s : Model_ in SumplTrenchSensor(s): { Modelmp Sensor(s} ��__ i_ odel'. f Y� Sump Sensors : { N1odeLanrcalLineLeakDetector. Model: j ]MphmucalLine Leak Detector. !-Model. e onic'Line Leak Detector Model LL ec nic Line Leak.Detector Model �X4L - arikOverfill)Hr =level SensModel: Ox�� nkOverfi�lllHr level Sensor: Model �v --- -- ----or: - -—. L.--__ - a -_ Sensor:-- ---- - Qther,S ec" equip.ta and model in Section E on Pa ,e 2 Other,S ec a ui .t e and model in Section E on Pa •e 2 Tank Tank ID: / n-TankGauinProbe: ; Model: I M / n-TankGau _gProbe; —_�j Model: arSpace or Vault Sensor: Model: ! AnnularS ace or Vault Sensor j Model: 4/05 r Sum lTrenchSensor s : Model: ' _i in Sum /Trench Sensor(s): Model: x, ill Sump Sensor(s): Model: ill Sump Sensor(s): Model. Mechanical Line Leak Detector. i Model: M e chanic al Line Leak Detector. Model: :r a orric Line Leak Detector { Model: L[p ornc Line LeakDetector Model. OZ L ankOverfill/Hi,h-level Sensor: { Model: ��_- _ _ I ankOverfill/High-levelSensor: ; Model: ]Other,Specify equip.t e and model in Section E on Page 2 E10ther,Specify equip.t e and model in Section E on Pa e 2 DispenserID: Dispenser ID: — �. _pen ser Containment Sensors: Model: ; ZG�P- Mis enserContainmentSe!j s . Model: �p Shear Valves . -�, hear Valves . ___' _ --' .--------- - Dis ens er C ontainment Flo a s and Chain(s) uDis enserContainment Flo a s .and Chain(s) Dis en_s er Drsp eris er ID__— s enserContainment Sensors: Model: __ ZU pens erContainment Senso s Model:: i She ar V alve(s). Sheaf Valoe __� =a Dis enserContainmentFloa s) an 'Ch infs i Dis enserContainmentFloa s and Chain(s) Dis enserID: Dis ens erID: _ __ i ]DispenserContainmentSens ors. Model: Dis�_enserContainmentModel. Shear Valves . "ShearValve s )]Dis enser Containment Floa s and Cli ' sj IDDisperiser Containment Float(s) 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. Certiflc ation-I certify that the equipment identified in this documentwas inspected/serviced in accordance with the manus' guidelines. Attached to this Certification is information(e.g. manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showu►g the layout of monitorn►g a m �Lent For any a ment capable of generating such reports,I hasealso attached a copy of the report, (check all that gip ): S tem set-up history report t - - -- T_echnicianNam_e_ffrrnt : YR: �L l,,r /L _Stature_ Certification No.: /7� S-6�2 License No.: _ $" —O `Testuz Compare—y Name: TAIT ENVIRONMENTAL SYSTEMS i Phone No (714)560-8222 — Page 1 of 3 03101