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MONITORING SYSTEM CERTIWATiON For Use By X111 Jurisdictions Within the State of California Authority Cited: Chapter 0.7, Health and Safety Coda; Chapter 16, Division 3, Title 23, Coli/in-nia Code of Regulations ' This form must be'used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared fur 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 (he local agency regulating UST systems within 30 Mays of Icsl (late. A. General Information Facility Name: ARCO Service Station No.: 6VZd Site Address: 1711 [ n ------ City: 611/?- Zip: i:acility Con(act Person: - _J_0A�✓ s�A,,_//el/ _ Contact Phone No.: 21 9- ley/ - 3 3 3,S Makc/Model of Monitoring System: 1-2.S J_�r _ Date of'I'csting/Service: f% -C73 It. Inventory of Equipment Tested/Certifie(1 Check the irpropriate boxes to indicate specific equi pment ins ected/serviced: Tank 1D: -- (_]In=Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: (RAnnular Space or Vault Sensor: Model: Wnnular Space or Vault Sensor Model: 7?Y3 '0-1/og i2vipMg Sump/Trench Sensor(s): Model: —)9V3V-3d Qiping Sump/Trench Sensor(s): Model: ?�I13 36 -gyp ❑Fill Sump Sensor(s): Model: _ 1// O _ 6Fill Sump Sensor(s): Model: (Mechanical Line Leak Detector. Model: YL Weclianical Line Leak Deteclur. Model: XL (]Iilcctlonic Line Leak Detector Model: rJo ❑Electronic Line Leak Deteclur Model: ❑Tank Overfill/High-level Sensor: Model: ❑'Tank Overfill/I{igh-level Scnsor: Model: ❑Other, Specify equip. type and model in Section E on Page 2 ❑Other, S2ccify equip. type and model in Section E on Page 2 Tank ID: n Tank ID: ❑ln-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: 44UAnnulir Space or Vault Sensor: Model: -7 -4 ❑Annular Space or Vault Sensor Model: WPiping Sump/Trench Sensor(s): Model: yg _ ❑Piping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: Mechanical Line Leak Detector. Model: XL ❑Mechanical Line Leal;Detector. Model: ❑Electronic Line Leak Detector Model: [-.]Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑'Tank Overffll/TTigh-level Scissor: Model: ❑Other, Specify equip. t )e and model in Section E on Pa c 2 ❑Other, Specify e ui .type and model in Section E on Page 2 Dispenser ID: Dispenser ID: _ ❑Dispenser Containment Sensors: Model: _ ❑Dispenser Containment Sensor(s): Model: ❑Shear Valve(s). ❑ Shear Valve(s). ❑Dis cnser Containment Floats and Chains ❑Dis enser Containment Float(s)and Chain(s) Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: _ ❑Dispenser Contaifunent Sensor(s): Model: ❑Shcar Valve(s). El Shear Valve(s). ❑Dis cnser Containment Floats and Chains ❑Dis 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). ❑Dis enser Containment Floats and Chains ❑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 -t 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 1, correct and a Plot Plan showing the layout of monitor ing,�eq}'�ipment. For any equipment capable of generating such reports, i have als( attached a copy of the report;(check all that apple): jfpcLSyslem set-up ❑ Alartn History report Technician Name(Print): -t1T'd Signature: _ Certification No.: /I License No.: 588098 Testing Company Name: TAIT ENVIRONMEN'T'AL SYSTEMS Pltone No.: _S916) 858-1090 Page I of 3 03101 Monitoring System Certificatioll