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MONITWING SYSTEM CERTIFIC , rICN For Use Bq All Jurisdictions Wthin the Spate of California Authority Cited: Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 23, California Code ofRegulat'ons This form must be used to documenttesting 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 formmustbe providedto 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.: 10595 Site Address: i 6100 N HWY 99 City_; STOCKTON Zip: 195212 1 --- ---- - - - -- --— --;-C-onta-c—tPh--on-e—No--_-_-- FacihtyContactn _-— -- J -- -� Make/Model of lUlonitoring System__ Date ofTestin- lg-Service: C B. Inventory of Equipment Tested/Certified Check the 2pprypriate boxes to indicate specific equipment inspected/serviced: Tank ID: 1 Tank ID: i ]Min--T ankGauging Probe: _ - _j-_o del_! ZS n_TankGauingProbe: _._._.. -.-._._Model: AnnularSQace arVaultSens or.__LModel: Zed- nnularSpace or Vault Sensor Model: LS ,Fectronic Sump/TrenchSensor(s): i Model: i��SumplTrenchSensor(s): _j Model: pSensor�_ i Model: i1lSumpSensorKs)_ ( Model: icalLine Leak Detector. I Model: 1UlechanicalLine LeakDetector j Model_ Line Leak Detector Model: Electronic Line Leak Detector Model: verfilYMM -levelSensor: Model: TankOverfil i -levelSensor: Model: Specifyequip.t e and model inSection E on Page 2 tYxer,Specify equip.t e and model in Section E on Page 2 T ank ID: Tank ID: Unnul Gau Probe: Model: i In-TankGau Probe: Model: Space or Vault Sensor: j Model: AnnularSpace orVaultSensor Model: um frrenchSmsorModel: Pi in SurttplTrenchSensor(O' Model: Sensor s : ' Model: illSumensor(s� Model: calLineLeakDetector. i Model: Mechanical Line Leak Detector. Model: c Line Leak DetectorModel: Electronic Line Leak Detector j Model: erfilUHigh-levelSensor: i Model: _ _ __ O rfill/Hi leveiSensor: 1 Model:-Specifyequip.t e and model in Section E on Pa e 2 Other,Specify equip.t e and model in Section Eon Pa e2 Dis ser ID: serID: ShearValv�s� 1 hearValve isp ens erContainmentFlo a s and Chain(s) Disp ens erContainmentFlo a s and Chain(s) Dis enserID: I S= Dis enserID: 7- is enser Containment Sensors: Model: s e ser ContainmentSensor(s): - ' Model: hear V alv�s). a ar V alve(sZ is enserContainmentFloa s and Ch ' s Dis ens erContainmentFlo a s and Chain(s) Dis enserID: DispenserID Dispenser Containment Sensors: Model: ,Dispenser Containment Sensor(s)_ Model: Shear 4She ar V alve.(s). Dis-p enser Containment Flo a s and Chain(s) and Ch ' s *If the facility contains more tanks or dispensers, copythis form. Include information for every tank and dispenser at this facility. C. Certification-I certify that the equipment identified in this document was inspectedfserviced in accordance with the manufactimers' 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 a u�ment. For any ee�ment capable of generating such reports,I Ihmeabo attached a copy of the report, (check all that appdyJ: S - tem set-up _ --__ --history- ort - - - - TechrncianName(Print). qr Signature: Certification No.: 13Stoo License No.: -TestingCompanyName_ TAIT ENVIRONMENTAL SYSTEMS Phone No.: 1 (?14)560-8222 Page 1 of 3 03101