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iOlo,TIri JRii�'i� SYSTEM CERTIFICATION • 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 Site Address: 130 S Wilson Way City: Service Station No. Stockton 5469 Zip: 95205 Facility Contact Person: ('L ly"21 Contact Phone No.: �L<:3?) Make/Model of Monitoring System: X -7(T Ni( Date of Testing/Service: B. Inventory of Equipment Tested/Certified +; s ectad/serviced• Check the a ro riate boxes to indicates specific e m men Tank ID: Tank ID: Fff ❑In -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: .Annular Space or Vault Sensor: Model: LE --7 j4Annular Space or Vault Sensor Model: G5::-7 ,Piping Sump/Trench Sensor (s): Model: _ EVPiping Sump/Trench Sensor (s): Model: CY- []Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Mechanical Line Leak Detector. Model: ,]Mechanical Line Leak Detector. Model: ,Eplectronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: A/!� Tank Overfill/High-level Sensor: Model: pCC7tj(}Ulc7 VoTank Overfill/High-level Sensor: Model: C–Sco ❑Other, Specify e uia and model in Section E on Pa e 2 ❑Other, Specify equip. a and model in Section E on Page 2 Tank ID: Tank ID: []In -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: MAnnular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: , Piping Sump/Trench Sensor (s): Model: tr3 ❑Piping Sump/Trench Sensor (s): Model: []Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: Kmechanical Line Leak Detector. Model: Cb -141c;0 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: Overfill/High-level Sensor: Model: C mcu , ,6t/vt� ❑Tank Overfill/High-level Sensor: Model: ,®Tank ❑Other, Specify equip. a and model in Section E on Page 2 ❑Other, Specify equip. a and model in Section E on Page 2 Dispenser ID: 144- Dispenser ID: 7,$ 0-7 Dispenser Containment Sensors: Model:i ]Dispenser Containment Sensor(s): Model: o_ / Shear Valve(s).Shear ❑Dis enser Containment Float(s) and Chain(s) Valve(s). Dis enser Containment Float(s) and Chain(s) Dispenser ID: U AQDispenser Containment Sensors: Model: Dispenser ID: /O Dispenser Containment en or(s): Model: c-iol (,E hear Valve(s).1 Shear Valve(s). TispenserContainment Float(s) and Chain(s) ❑Dis enser Containment Float(s) and Chain(s) Dispenser ID: Containment Sensors: Model: ov i Dispenser ID: / iU Dispenser Containment ensor( Model: / 2Dispenser A Shear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) Shear Valve(s). ❑Dis enser 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; (check all that ply): ❑ System set-up ❑ Alarm history r� Technician Name (Print): Signature: Certification No.: L6 b ? 7 > License No.: 588 098 Testing Company Name: TAIT ERVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222 Page 1 of 3 03/01 Monitoring System Certification