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MONTI ZING SYSTEM CERTIFIWTION ` 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.: 6100 Site Address: 25775 S. Patterson Pass City: Tracy Zip: 95376 t.&,- - C(K _ -3-3 Facility Contact Person: So H wJ `,r r G+a'T F �Z Contact Phone No.: Make/Model of Monitoring System: 1lEG e.),.59_ f2 i 77-s: J s' d Date of Testing/Service: :312-6O B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/serviced: Ta ID: Y� Tank ID: n-Tank Gauging Probe: Model: $c173 90 0 7 215-Tank Gauging Probe: Model: c'--Y73 io o �^�iulular Space or Vault Sensor: Model: 7gv3yc- q,,-7 ular Space or Vault Sensor Model: 79y "u-- o 1 ing Sump/Trench Sensor(s): Model: X94 �, �Ipng Sump/Trench Sensor(s): Model: 7 S. z� ill Sump Sensor(s): Model: -7w.3FL�,--Lc,9 211 Sump Sensor(s): Model: 71),,-36 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: [ ctronic Line Leak Detector Model: PL r f) Va� ronic Line Leak Detector Model: [2Tank OverfilUHigh-level Sensor: Model: '7 f a�191-c-,-- f Overfill/High-level Sensor: Model: 7ge)o 9 i - c;oi ❑Other, Specify equip. type and model in Section E on Page 2 ❑Other, Specify equip. type and model in Section E on Page 2 Ta ID: 2 ST,annkk ID: c / Tank Gauging Probe: Model: 6-17310 l07 [R<n-Tank Gauging Probe: Model 1>739a- I o LSA ular Space or Vault Sensor: Model: 7 q y3 j o -t c [ ular Space or Vault Sensor Model: _717e( yp 2ping Sump/Trench Sensor(s): Model: -7 943go- Zo g [;Piping Sump/Trench Sensor(s): Model: -7 9f3P.o ' c Wim"` Sump Sensor(s): Model: 7 c -zopZ 1 1 Sump Sensor(s): Model: -7Ver3 ,. ?� ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑gtoctronic Line Leak Detector Model: Clee�lronic Line Leak Detector Model: C L i ank Overfill/High-level Sensor: Model: 7�po I/ -cam/ [ank Overfill/High-level Sensor: Model: 7 9GcD 1 i-octal ❑Other, Specify equip. type and model in Section E on Pa e 2 ❑Other, S2ecify e ui e and model in Section E on Pa e 2 D^is enser ID: Z Di enser ID: Ll� penser Containment Sensors: Model: 7yy ,-Z Di Containment Sensor(s): Model: 7yc/j Io$ Shear Valve(s). Q18'6ear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) ❑Dis enser Containment Float(s) and Chain(s) Dis enser ID: — Dis enser ID: enser Containment Sensors: Model: 79y3 - [ is enser Containment Sensor(s): Model: 7 y cQ -lc Shear Valve(s). hear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) ❑Dis enser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s) []Dispenser 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. 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;(che k all that apply): System set-up 21 Alarm history re rt Technician Name(Print): V ce4 Signature: Certification No.: / License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222 Page I of 3 03101 Monitoring System Certification