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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Wthin the Slate of California Authority Cited: Chapter 6.7, Health and Safety Code;Chapter!d,Avision 3, Title 23, California Code of Regulations This form mustbe usedto document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system control gone 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 Faci' Name: ARCO PRODUCTS COMPANY Service StationNo.: !0595 Sita Address: 6100 N HWY99 C' STOCKTON_ _ _ ....._... _. Y_ ZiV'. 95212 FacifitY Contact Person `Sin , S c Contac!Phoas No�_i_r tj c�,- u p -3 3:1 �� (L 7(S 3 T D Date ofTes ' arnica: s- B. Inventory of Equipment TestedMertified Check the date boxes to indicate specific elgkMext ected/servicei: Tank ID: Tank M: r0th—*4 giProbe; Model ` 7390 /a TenkC3augxagProbe _ i h+IodeL 7 e §pAce9!yaultSensor Model• ulofSleeofVaultSModel: LS3 umreachSensor(p) Model: d� i ia�SumpJTreaohSeasor Model:Seasor :__.`__..___ . Model �1-� itlSumpSeaear s: i Model:aicelLineLeakDetector. Model: : echenic&ILineLeakDetector, IModel:cUnaLookDetectorModel: C,�7— chow Line Leak Detector I Model:verfilllHi levelSeasor Model Ci��-cK� eakOverfilUH' IevelSeasor. ; ModeS-ec' e e and model is Section E on P e 2 Other S ac' a !Me gad model in Section E on Page 2 Tank ID: 91 Tank ID: n-TaakC3au nEProbe: -_ _ Model: ! c.(73 90/6'7 In-TankGauging Probe: �Model rmularSpnce or Vault Sensor_. : Model L S nnularSQace or Vault Sensor Model: Y ;_g SumplTrenchSeasor�s�: : Model $ ao� Pip�Sump/TrenchSensor�s) Model ' ---... SumpSew or�s _._.__ ._. ._.. Model_ illSusapSeasor(a)—.__.._.__._ Model: . M chanicalLineLeakDetector. Model ' lUIechenicelLine Leak Detector. ! Model: ctronic Line Leak Detector Model: ectroruc Line Leak Detector Model: aak0vedi1UHiah,-1eve1Sen9or:_ Model: yam. hlevel.Seasor: ; Model Other,Spoeft e .type and model in Section E on Page 2 e S ec' a ui .t e and model inSection E on Pa e 2 i Di s enserID: /-F Die or ID: 3— i enserContainmentSensors: ; Model: ') } 4.3Jb .� ispenserContainmentSenso�s�, — _Model: . y3 ha rVaty s . hearvsly s . JaDis enserContainmentFloa s and Ch%e e enserContainmentRo s and Disuenser ID: S= onset ID: 7-- eruerCouteuunentSenaors: Model_ 79y enserCotuammentSeasor(s);_ ��Model: -794i hearvalve(s) _ _._ fD eerand Ch ' ss-Dispenser Containment Flo a s and Ch ' s Dispenser ID. I Dispenser ID: LDispenserContoinmentSensors_ Model is enserContainmentSanso s : Model: wiseenser P ��hearValy s . SContainment Float(s)and Ch ' s Die ens er Containment Flo a s and Ch ' 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 docwnent was ir"ected/serviced in accordance with the manufachnea' guidelines. Attached to this Certification is information(e.g.manufasturers'checklists)necessary to verify that this information,is correct and a Plot Pha showing the layout of monftor3nguipmeat For any equipment capable of generating such reports,I haealoo attwhad a copy of the report;(check all that appy): 3ystat sbt u� �rra history.report _- - _ . _. Techructea Name(Print): A` Signature: -- CertrfxcationNo.: 077LicenseNo": .5 -C TestingCompessyNnme TAIT ENVIRONUFNTALSYSTEMS Phonallo.: (714)560-8222 Page 1 of 3 03N 1