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To: Fm:Reservations 12:12 01/17/05 PG 001 <br /> N,j0NTToRING SYSTEM CERTIFICATION <br /> For Use By All Jurisdictions Ifithin the,State of California <br /> Az:thority Cifcd:Chapter 6.11,Health and Safety Code,Chapter 16,Division 3, Title 23, California Code of Regulations <br /> This form must be usedto document testing and servicing of monitoring equipment.A separate certification or report must be prepared <br /> for each mohitorin^ 7,ystera control panel by the technician who performs the work. A copy of this form must be provided to the tank <br /> system o+=-mer/operator. The ownerfoperator must submit a copy of this form to the local agency regulating UST systems within 30 <br /> days of test date. <br /> A. General Information <br /> ARCO PRODUCTS COMPANY Service Station No.: 0595 <br /> Site Address: 6100 N HWY 99 City: STOCKTON Zip: 95212 <br /> _I 5 Contact.Phori.IT,:.: 1; , 3 - <br /> �•icihr.;Contact Person: �- ,. -�- <br /> c , Date ofTestizi ;S?r-rice: t ,; 10 <br /> Ml .dre/lvlodelofMorutorin_.,,Leen;: -B. Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate aecific equipment istspectedlserviced: <br /> l Tan) 1= Tank ID: <br /> t, -T:iitl:['_;•it_t,ui Probe: Pdlodel: e(��:''t, ,i� ' ti-'T;n',1:Cialigin;_Probe Mod 1: �+tr ii'!• /� <br /> L <br /> [X rt-•iularSpace or Vault Sensor: Model: Z- S i �viulur,Space or Vault Sensor I'��Iodel: <br /> nt_ImplTrenchSensor(s): Model: "r ='Jit r'ipir,gSutnp/TrenchSensor(s): Model: <br /> �rr115ump Sensor t,$); Model: `cl ( ill Sump Sensor(sl: Model: <br /> Model: <br /> EIvlechanicalLine Leak Detector. Model: ❑I',+Iccli,uic:�lLineLeakDetector. <br /> (�1`tectrorlic Line Leak Detector Model: C%t le tronic Line Leak Detector hdodel: - <br /> ankOvexfilUHih-le-rel �rnsor. <br /> C ,k OverfilUHl h-lr.::el Sensor: i'aI del: 7 C i s'c ! r on <br /> ❑Other,Specify equip.t e and model in Section E on Page 2 ❑Other'.peen= rquir.t�:pe acid Iuodrl iri S cell n E on Pa e2 <br /> D: r"! Tank ID: <br /> T.iil:Gatr�ingProbe: Model: c!7110 is ❑In-Tank Model: <br /> �J. rriul•ir 'pace or Vault Sens or: Model. !. 5� ❑rrui tial`'pace orVaultSensor Model: <br /> Winn-21uniplTrenchSens of(i): r1 j: 15=4:'s:FJ' 'f' [ Piping StunplTrenchSensor(s): Model: <br /> [_'rl - Model: <br /> : ..tinl: ,.?Iisof 'L..): IVlodeL ljf ,;1 :D' ❑FillSuml,ti�ensorfs): <br /> ❑Iv(echanicalLine LeakDetector. helodel: ❑Mechanical Line Leak Detector. Model: <br /> �i ctronic Line Leak Detector Model: Y' ❑E1ectrc oic Line Leak Detector Model- <br /> anYO-rerfilUHi^h-levelSensor: Model: -7 ;�4�! ❑Tank Overfill/HiEh-levelSensor: Model. <br /> SpectLjjui .t e and model in Section E on Pale 2 ❑011ier,S ,eciiTr e iii i.t,. e:lid m•IfICI m Sectaon E.on Pa e 2 <br /> Eio•penserID: !- 2 Dispenser ID: <br /> r _!iapenserContairunentSensors: Model: '? 1;; 13,r-C- :;k-­F- L,]'ilisl:enserllontainmentSens ort;sl: Model: -;eJ c. " != <br /> [y;heafValve(s). <br /> ❑Dispenser ContainmentFlo a s and Ch s ❑Dis enserContainmentFloat('s)andClisitils"1 <br /> Dispenser ID: S= /- Dispenser ID: <br /> l - <br /> [,,•';+ispenser Containment Sensors: Model: ',l'i: t i' ❑DispenserContairmentSensorfsj; Model: <br /> (J"iliea3'•-iii ll9l. {_J: <br />