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MONI" RING SYSTEM CERTIFY ATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, 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 panel 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 Facility Name: ARCO PRODUCTS COMPANY Service Station No.: 6313 Site Address: 1100 S.Main Street City: Manteca Zip: 95337 T Facility Contact Person: V Gh N AC _ Contact Phone No.: ul_ (.0 - 333 S Make/Model of Monitoring System: e je ti `T�s- _�� Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check the ap2ro2riate boxes to indicatespecific equipment ins ected/serviced: Tank ID: Tank ID: � In-Tank Gauging Probe: Model: 7 39v -/a`I ®ln-Tank Gauging Probe: Model: �k 10 a-1 Annular Space or Vault Sensor: Model: -1 39 0-4-,0 ClAnnular Space or Vault Sensor Model: lijy v-ti u [Piping Sump/Trench Sensor(s): Model Lt 3aa 20,y [2Pipmg Sump/Trench Sensor(s): Model. ❑Fill Sump Sensor(s): Model: [3Fill Sump Sensor(s): Model: (5]Mechanical Line Leak Detector. Model: L 0 kn pMechanical Line Leak Detector. Model: Y7J3-7) ❑Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other,Specify equip. a and model in Section E on Page 2 []Other,S eci aqui a and model in Section E on Page 2 Tank ID: Tank ID: 01n-Tank Gauging Probe: Model: Y'q 11-1 -}n`i ❑In-Tank Gauging Probe: Model: BAnnular Space or Vault Sensor: Model: '71ty'71t 14 a - 14 1 ❑Annular Space or Vault Sensor Model: ®Piping Sump/Trench Sensor(s): Model: IIK ho 'r ❑Piping Sump/Trench Sensor(s): Model: []Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: JDMechanical Line Leak Detector. Model: S-T P m LO ❑Mechanical Line Leak Detector. Model: []Electronic Line Leak Detector Model: ❑Electronic Line Leak Detector Model: []Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: []Other,Specify equip. a and model in Section E on Page 2 ❑Other, Specify equip. a and model in Section E on Page 2 Dispenser ID: ( Dispenser ID: �--Y (Dispenser Containment Sensors: Model: 714 . -) 35KI RjDispenser Containment Sensor(s): Model: 7fu�ta 3t/ q Shear Valve(s). I;a Shear Valve(s). []Dispenser Containment Floats and Chains ❑Dis enser Containment Float(s)and Chain(s) Dispenser ID: - Dispenser ID: 5-/o [3Dispenser Containment Sensors: Model: 75q;,r+ -3L1 (Dispenser Containment Sensor(s): Model: 4 t� ?c i q Shear Valve(s). ® Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s) [-]Dispenser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: ��— ®Dispenser Containment Sensors: Model: '?Ci Lt1 r+ - zi V3Dispenser Containment Sensor(s): Model: 71 y.jai J] Shear Valve(s). 6 Shear Valve(s). ❑Dis eraser Containment Float(s)and Chain(s) ❑Dis enser Containment Floats and Chain(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 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,I have also attached a copy of the report;(check ll�pply � System set-up U Alarm history report Technician Name(Print): rye Signature: U Certification No.: ?°)1 1()F License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222 Page 1 of 3 03/01 Monitoring System Certification