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Doc-17-2003 09:11 am From-ARCO PRODUCTS +714-670-3095 T-739 P.001/004 F-282 MO RING SYSTEM C;r:tiTIN t to v r Use By Ah Jurisdictions YYrthin ihe.S7ate u(Cah),.. la Authority Cfled- Chapter 6.7,Heakh and Safety Code; Chapter 16,Dh-ision 3, Title 23, Calffornia Code of Regidarions This form must=used to document testing and servicing of monitoring equipment.Ascpa_rate certification or report must be arenared for each moritoriie system control Ranel by the technician who performs the work, A copy of this form must be provided to the / `_J system owner/operator. The owner/operator must submit a copy of this fora:to the local agency regulating UST systems within Inv�DD days of test date. A. General Information UkL 1 ' 2003 Facility Name: ARCO PRODOCTS COMPANY Service Station No.: 6313 41 I HEALTH Site Address: 1100 S.Main Street City, Manteca Zip: siffiWIT/SERVICES Facility Contact Perion: �1 G},N ,� e-• _ Contact Phone No.; ui S13 S Make/Model of Monitoring System: c 'n aG w 'TSS . - Date of TestingrService: B. Inventory of Equipment Tested/Certified Check the appropKiate boxes to indicate spetifle equipment inspected/Seri iced: Tank ID: 2 i Tank ID- �)In-Tank Gauging Probe: Model: 514 7_Jp3•Ia•? 1 Oln-Tan)(gauging Probe: Model: Annular Space or Vaulc Sensor; :Model: 7g y 31 t.-4,0 cLi ©.kM=hr Space or Vault Sensor Model: Q'1 14 l;Piping Sump/Trench Scusor(s): Model: w 3pPiping Sump/Tr=ch Sensor(s): Model• 71 ,(.V,- Ya'r ❑Fill Sump Sensor(e): Model: []Fill Swnp Sensor(s): Model: 53Mechanical Line Leak Detector. Model: (_19 2-sn F,�iMechaiiical Line Leak Detector. Model: ^Z7} ❑Electronic Line Leak Detector Model• ❑Electronic Line Leak Detector Model: ❑Tarek Ovcrftll/High-level Sensor. Model: []Tank CGverfcll/High-level Sensor. Model: []Other,Specify equip,t e and:nodes ir.Section l✓on:p•ne 2 ❑Other, specify equip.rope and model;n Section E or.P_aee 2 Tank IIs: Qi r Tank ID: On-Tank Gauging Probe: ?Model: rte "14 I i,4`S ❑In-Tank.Gauging Probe: Model: EAnnular Space or Vault Sensor: Model: 5j�J, c )'i. [:Annular Space or'Vault Sensor Model: ®Piping S pi Trench Sensor(s): Model: ttLt 7:4 • []Piping Sump/Trench Sensor(s): Model: GFill Sump Sensor(s): Model: q ❑Fill Su'Op Sensor(a): Modes: ZMechanical Lire Leak Detector. Model: 7? m:.O ❑Mechanical sine Leak Detector. Model: CElectronic Line Leak Detector Model: ❑Electronic Line Leak Detector Madel: ❑Tank Overfill/High-level Sensor: Model: ❑Tank OverfilifRigh-level Sensor: Model• ❑Other,Spedfy equip. and model in Section E on Pae? Other S-Deci equip. and model in Section Eon Page 2 Dispenser M: ( Dispense c ID: [$Dispenser Containment Sensors: Model: 74 It W�%f ®Dispenser Conrainmeni Sensor(s): Model: W u3n 'fit Q Shear Valve(s). (2 Shear Valve(s), [7Dispenser Containment Float(s)and Chains D enter Containment Floats)and Chain(s) Dispenser ID: - v Dispenser ID.- 9-/o ®Dispcnscr Containment Sensors: Model: hk;o -1L( ( Dispenser Containment Sensor(s): Model Shear Valve(s). CM Shear Valve(s). ElDispeuser Containment Floats and Chain s ❑Dis enter Containment Float(s)and Cha s) Dispenser ID: S-,— Dispenser ID: II-ic- 2Dispenser Comainnent Sensors: Model, 1 �7Z,- i•+ ,�Diapenaer Containment Sensor(s). Model: 7� J2 Shen Valve(s), ® Shear Valve(s), j ❑Dis eraser Containment Float s' and Chain(s) Dia eager Containment Float(s)and Chain(s) *If the facility contains more tanks or dispensers,copy this fora. Include information for every tank and dispenser at this facility. C. Certification-I certify that the equipment identified in this document was inspected/scrviccd In accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. nranufactilMrs' checklists) aeaessary to verify that this information is correct and a Plot Plain showing the layout of monitoring equipment. For any equipment capable of generating,such reports,I have also attached a copy of the report;(check it that apply :, 'g System set-up Q Alarm history report Technician Name(Print): Sipanue: Certification No.: q).% License Nil: 588 098 Testing CompanyNarre: TAIT ENVIRONMENTAL SYSTEMS _ Phone No.: 1'714)560-3222 Page 1 of 3 03/01 Monitoring System Certification