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Feb 21 U3 1U: 49a 1H1T Environmental 5yatem [9151 858-1011 p. 5 MONITORING SYSTEM CERTIFICATION For Use By Ali Jurisdictions Within the State of California Authority?Cited- Chapter 6.7,Health and Safety Code; Chapter 16,Division 3, Title 33, 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 pare by the technicizn who perforins the work. A copy of this form must be provided to the tank system ownerieperator. The owner/operator must submit a copy of this form to the local agency regulating -ST systems within 30 days of test date. A. General Information Facility Name; ARCO PRODUCTS COMPANY Service Station No.: 0595 Site Address: WON.N.HIGHWAY 99 City: STOCKTON Zip: Facility Contact Person: Contact Phone No.: Make.lModel of Monitoring System: V4 -f L$ 3-1-0 Date of Testing/Scrvice: C73 B. Inventory of Equipment Tested/Certified Check the approEriate boxes to indicatespecific equipment ins ectedlserviced: Tank ID: P I jn Tank ID: 7 S :11n-Tank Gauging Probe: Model. /V110 ❑In-Tank Gauging Probe: Modrl: Na r-e- 7rAnnular Space or Vault Sensor: Model: L s ) EyArucular Space or Vault Sensor Model: Z S 7 'Piping Sump french Sensor(s): Model: 7'717,P ,(: (2Piping Sump/Trench Sensor(s); Model: 254y -�,� ]Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ]�SwChanical Line Leak De[ectur. Model: ❑Mechanical Line Leak Detector. Model: EElectronic Line Leak Detector Model: C 00 26ectronic Line Leak Detector Model: G ']Tank Overfill/High-level Sensor: Model: ❑Tank OverfilMigh-level Sensor: Model: ❑Other,Specify a to .type and model in Section E on Pae 2 ❑Other,Spec Ly equip. a and model in Section E on Page 2 Tank ID: Tank ID: ❑In-Tank Gauging Probe: Model: ,,� ❑In-Tank Gauging Probe: Model: 2Annular Space or Vault Sensor: Model: t []Annular Space or Vault Sensor Model: 2Piping Sump/Trench Sensor(s): Model: t--T ❑Piping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: []Mechanical Line Leak Detector. Model: []Mechanical Line Leak Detector, Model: 2Electronic Line Leak Detector Model: C Jp 7 iiM"tronic Line Leak Detector Model: ClOW []Tank Overfill/High-level Sensor: Model: []Tank Overfill/High-level Sensor: Model: ❑Other,Specify c#2. e and model in Section E on Pae 2 DOther,Specify equip. e and model in Section E on Page 2 Dispenser ID: Dispenser ID: 20ispenser Containment Sensors: Mode l:—,,wM Z0 [Dispenser Containment Sensor(s): Model: ehear Valve(s). ❑ Shear Valve(s). ❑Di enser Containment Float(s)and Chain(s) ❑Dispenser Containment Float s}and Chains Disperser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: ❑Dispenser Containment Senscr(s): Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Diu enser Containment Floats and Chain(s) ❑Diu 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), Z]DisTenser Containment Floats and Chain(s) ❑Di enser Containment Float(s)and Cha' s) *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and disperser at this facihty. C. Certification -1 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,1 have also attached a copy of the report;(che•k all that apply): ❑System set-up 0 Alarm history eport Technician Name(Print): r a IL 6Lw/C Signature: Certification No,: Q/2 4' License No.: 583 091r— Testing Company Fame: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page t of 3 03/01 Monitoring System Certiilearlon