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MONITORING SYSTEM CERTIFICATION For Use By Al Jurisdictions within the Slate of California Authority Cited: Chapter 6.7, Health and Safety Code,- Chapter 16, Division 3, Tittle 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 -- — -- ------------ FacilityName: ARCO PRODUCTS COMPANY Service Station No : ,5469 _-_ �_ -- _ --- - -- - - -C-it-v:---S-,T--O--C-KT-ON---i-Zi--,-- S - it ---- - ---- -- - ------ Site Address: 130 S WILSON WAY City_ STOCKTON Zip_ 95205 Facih Contact Person: `S�� 1� ;� -- - �� P.� C ontact Phone N o.: �.� Z - c/g _ `.23T - ------ - -- - -._ . _--_._-_- --- ----- -ofMo ---------- - - ---- . --------1-D ate ofTestin er rice: G c MakeJModel of Monitoring System__ . n C y. -_ er E. Inventory of Equipment Tested/Certified V1...ar A.. annrnnriate boxes to indicate specific eouipment hmectedlserviced: --- Tank ID:^! --IL-- Tank ID- QIn-Tank Gauging _Probe: ' Model: LeA_rnulerSpace or Vault Sensor:_ 1 Model: LS 7 12ipingSumpfrrencb.Sensor(s): Model 4-.:.. EFillSumpSensor (s): I Model: Dln-Tank Gauging Probe: Model: BA arSpace orVaultSensor Model: '1 S rpingSumplTrea(ch Sens orSsl __I Model: ❑Fill Sump Sensors): Model: echarucalLine Leak Detector. Model: L I echanicalLiaeLeakDetector. J Model: 1-0 ]Electronic Line Leak Detector i Model: DElectronic Line Leak Detector 1 Model wTankOverfill/Hi level Sensor: I Model: pother, Specffy Spec'equip. t e and model in Section Eon Page 2 j [IT ankOverfilllHi -level Sensor. Model El Other, Specify a ui . IyEe and model in Section Eon Page 2 Tank ID: -1n-Tank Gauging Probe: Model: rin _Sppace or VaultSensorModel: /,S2 SumpfrrenchSensor s : I Model: L r_RZSu ID: _Tank ❑In TankG�& robe__- i Model_ DAnnularSpace or Vault Sens or i M_odel:_ ® r sPipingSump/Trencb.SensoModel: mpSensor s:— I Model: ❑FillSumpSenscr(sZ_ ;_Model: 1]MechanicalLine Detector. Model: , dMechanicalLine LeakDetector. I Model: _Leak electronic Line Leak Detector Model: 1 dp-�r WElectronic Line Leak Detector Model: Tank.Overfa/Hi level Sensor: Model: ! INTank Overf&Mi level Sensor: I Model: tjother, Specify a ui . t e and model in Section Eon Page 2 Other, S ec' a ui. type and model in Section Eon Page 2 D' ser ID: I-2. _,-.. - - J1tijensercontainment Sensor -s: - Model: DKosis enserContainmentFloa s andCh ' s Dis enserID: enserCont•a-inm.__e-nt—Sensor(!): Model_ C �i IshearValva rs enserContainmentFloa s and Ch ' s DispenserID:_J % i -/o j iqp ens ter Containment Sensors:4VIode133�� _ ��,( hear V alv s . ]Drs e-nse-rContain-mentFloa s and Chain(s) DispenserID__ i-12 -/ BTSis nserContainment.Sensor(�: Model: 3(,aia- ,/ __. . hear V alv s D Disp ens erContainmentFlo a s and Chain(s) Dispenser ID: S-/ _-- __.__ is enserContainmentSensors_ j Model_ -3 3c, � - 6c9 hear Valve(s). - -_ -- Dis enserContainmentFloa s and Ch ' s Dispenser ID_ ❑Dispenser ContainmentSenso s)_ Model: ElShearValve(s). ❑Dis enserContainmentFloa s and Ch s *If the facility contains more tanks or disp ens ers, 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 manufacbmn' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this h&rmation is correct and a Plot Plan showing the layout of monitoring equipment For any equipment capable of generating such reports, I hzealso attached a copy of the report; (check all thatRpiy): ❑ tem set-up ❑Alarm history rer rt hricran Name (Print): 17/Lk Signature. Tec _ - - Certification No.: License No.: Testin Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: ; (714)560-8222 Page 1 of 3 03101