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N40NITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Wthin the cafe 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 revoit 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 _ FacihNnme: �ARCO PRODUCTS COMPANY ! Service Station No.: 16020-' Siie Address 11711 E YOSEMITE i Com•' i MANTECA i Zip: 195336 Facilzi Contact Person: "t , Srp;� Contact Phone No.: �1p y-(�c(2^ 3 i Make/Model ofMonitozingS stem: ^U� TCS 3rn _ _ Date ofTestinoervice: „t bbl B. Inventory of Equipment Tested/Certified Check the date boxes to indicatespecific e ' ment ected/serviced: Tank ID: ! Tank ID: [it nkEkugngProbe: i Model: r, n- ankGaugingProbe: Model: ,rtilarSS�ace or Vault Sens or: ' Model: 9 q ularS nce or Vault Sensor �Model: qi,Sum�renchSensor(s): Model: 9 in S renchSensor s : Model:mISensor s . Model: x ills Sansoz Cs): i IVlodel: ��- anicalLineLeakDetector. ! Model: ! echanicalLineLeakDetector. ! Model:onic Line LeakDetector ! Model: I e onic Line L.eakDetactor ! MoOvedfill/Hiei-levelSensor: M odel: 5-cam,; ank Overfi111Hi -level S ens or: M o del7�}�,S ec' equip.t e and model inSection E on Page 2 Other,S ec' a !! . e and model in Section E on Pa e2 Tank ID: TenkID: ! Vechardc GaugingProbe_ Model: ! n-TankGau ' Probe: i Model:space or Vault Sensor: Model: � AnnularS ace or Vault Sensor ; Modelu /Trench Sensor(9 : Model: j Sys ?ti Pi in Sum JTrenchSensor s-�ModelSensor s): LMadeL 9tP3 - Fi1lSumpSensor(s): Model: &ILineLeakDetect.or. :_Model: ; IUlechanicalLineLeakDetector. ' Model:- Ele onic Line LeakDetector�l Model: !. Electronic Line Leak Detector Model: Overfill/High. evelSensor. Model- -7Y�„�,►Y ankOverfil]lHigh-levelSensor: Model: IffOther Sec' a ui .t e and model in Section E on P e 2 Other,S ec' t e and model in Section E on Pa e 2 Dispenser ID:_ -2 Dis enser ID: _ ,-.rnispoens enserContainmentSensors: Model: 79Sd� ?.ori+- enser ContainmentSenso s :r Valves . Valves�Zer Containment Flo n s and Ch ' s is enser Containment Floa s end Ch ' s - DispenserID: ! -/L -/L Dis enserID: enser Containment Sensors: ` Mo el�g�3 enser ContainmentSenso s; oriel: 9 -;-- �___ _earVelveU_- - - ! 0-A ear _ Dis enser Containment Floa s and Ch s _ - Dis enser Containment Flo a s and Ch ' s - Dis�enserID_ Dis enser ID: DispenserContninme_ntSensors:Model: ; Di enser ContainmentSensor(s): Model: Sheer Vaty s . ----- °SJ Shear Valves). _ Dis enser Containment Float(s) and Ch ' $ - s is enser Containment Floss 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 idexd&d in this document was inspectedherviced in accordance with the manufacbm w, 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 mcnitol*equipment For any e lament capable of generating such reports,I1mg1 o attached a c9L f the report- (check all that a i ❑ System set-up kistor ort _Technician Name(PrintZ-+.' G "-Z Ler= 1 Signature: — CertificationNo.: 77 License No.: TestgCompanyName: TAIT ENVIRON>RENTALSYSTEMS Phone No • (11 )560-8222 Page 1 of 3 03101