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MONI _ JRING SYSTEM CERTIF ..-ATION 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 Service Station No.: 5469 City: STOCKTON Zip: 95205 Facility Contact Person: j 54'r 4y_1L_ Contact Phone No.: VG )'i LT-- Make/Model of Monitoring System: �,J{Zt,.► Date of Testing/Service: 1,D -L3 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific eauipment inspected/serviced: Tank ID: X1 Tank ID: ❑1n -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: 'Annular Space or Vault Sensor: Model: 1- f]Annular Space or Vault Sensor Model: C f [Piping Sump/Trench Sensor (s): Model: ®Piping Sump/Trench Sensor (s): Model: tr - [Fill Sump Sensor (s): Model: Ly} OFill Sump Sensor (s): Model: t.j *Mechanical Line Leak Detector. Model: 2Mechanical Line Leak Detector. Model: wil [Electronic Line Leak Detector Model: / ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: _ Model: ❑Other, SpeciLy equip. a and model in Section E on Pa e 2 ❑Other, Specify aqui a and model in Section E on Pa e 2 Tank ID: 4 t Tank ID: ❑In -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: Annular Space or Vault Sensor: Model: ❑Annular Space or Vault Sensor Model: [BPiping Sump/Trench Sensor (s): Model: L( -j ❑Piping Sump/Trench Sensor (s): Model: [2]Fill Sump Sensor (s): Model: []Fill Sump Sensor (s): Model: [Mechanical Line Leak Detector. Model: ❑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, SEecify equiE. type and model in Section E on Page 2 []Other, Specia equip. a and model in Section E on P Dispenser ID: !,I Dispenser ID: -L-Y J�jDispenser Containment Sensors: Model: ®Dispenser Containment Sensor(s): Model: j3n tl c -ro 1 Shear Valve(s). 4100 IM Shear Valve(s). Dispenser Containment Float(s) and Chain(s) ❑Dis enser Containment Float(s) and Chain(s) Dispenser ID: Dispenser ID: r9- io Dispenser Containment Sensors: Model: 3 oZ/ Z -dal (Dispenser Containment Sensor(s): Model: V a4 t- �l Shear Valve(s). 0 Shear Valve(s). Dispenser Containment Float(s) and Chain(s) ❑Dis enser Containment Float(s) and Chain(s) Dispenser ID: S'- �_ Dispenser ID: It-/t- [�Dispenser Containment Sensors: Model: 3YOUL l [Dispenser Containment Sensor(s): Model: )Cut--fU 0 Shear Valve(s). ❑ Shear Valve(s). []Dispenser 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; (check all jhat apply)* ❑ System set-up ❑ Alarm history r po Technician Name (Print): ,�, t p� Signature: /S, ' Certification No.: 393`tlr License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222 Page 1 of 3 03/01 Monitoring System Certification