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MONITOING SYSTEM CERTIFI(WION 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 FacilityName: ARCO PRODUCTS COMPANY Service Station No.: 6020 Site Address: 1711 E YOSEMITE City: MANTECA Zip: 95336 t. Facility Contact Person: i Pis t"p U! Contact Phone No.: 5-03 - Make/Model of Monitoring System: i1.e e_d t r W.av+ PLS 3 5"t' Date of Testing/Service: y t-7 0 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ected/serviced: Tank ID: 7 Tank ID: []In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: nnular Space or Vault Sensor: Model: 17c,,3cj 6-C40-1 Annular Space or Vault Sensor Model: 5 35 o --lo cr Piping Sump/Trench Sensor(s): Model: -)W:3W';.off iping Sump/Trench Sensor(s): Model: -7 S ly 3 J-o- []Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: Mechanical Line Leak Detector. Model: >eL,D Ssamechanical Line Leak Detector. Model: )<e_jp []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.t e and model in Section E on Page 2 ❑Other, Specify equip. a and model in Section E on Pae 2 Tank ID: Ci I Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: nnular Space or Vault Sensor: Model: 4 o - o 5 ❑Annular Space or Vault Sensor Model: Piping Sump/Trench Sensor(s): Model: y -SO 'a ❑Piping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: Mechanical Line Leak Detector. Model: Lil ❑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.t e and model in Section E on Pa e 2 ❑Other, Specify equip.t e and model in Section E on Page 2 Dispenser ID: t Z Dispenser ID: ispenser Containment Sensors: Model: Dispenser Containment Sensor(s): Model: 2 p hear Valve(s). 'B Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s) ❑Dis enser Containment Float(s)and Chain(s) Dispenser ID: S I, Dispenser ID: 48 ispenser Containment Senso s: Model: 2 0 Dispenser Containment Sensor(s): Model: 20 '&Shear Valve(s). t&Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s) []Dispenser Containment Float(s)and Chain(s) Dispenser ID: It 110 Dispenser ID: 11 i Dispenser Containment Sensors: Model: 70 ispenser Containment Sensor(s): Model: -2-019 Shear Valve(s). �3 Shear Valve(s). []Dispenser Containment Float(s)and Chain(s) []Dispenser Containment Float(s)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 momtorm quipment. For any equipment capable of generating such reports,I have also attached a copy of the report; (che all that apply): System set-up L3 Alarm history repo Technician Name(Print): y� /� L Signature: Certification No.: , q/'/Sr3 a License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page 1 of 3 03/01 Monitoring System Certification