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MONITORING SYSTEM CERTIFICATION Fbr Use By All JtQisdichons VAthin the State of California Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23, California Code ofRegulations This form must be used to document testing and servicing of monitoring equipment.Asseegarate certification of regort must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this formmustbe 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__ -FncrSityldeme_� ARCOFRODUCTS COMPANY Service StationNo.- !6080.--.---------_.__.._.-.-__-- - ' Site Address: .85 E LOUISE AVENUE City LATHROP ; Z—p:_ 95330 F ncilitg g ontact P erson 1"��„ �r l.o" °. --- _Contact Phone N o.: 114n /o V9 Make/Modelof Monitoring System: j�'�!,C6�5 � Date ofTastinoeryice: / B. Inventory of Equipment Tested/Certified Check the NpEnriate bones to indicate 20cific next bwpected/serviced: Tank ID: Tank : fe kGnugiu Probe: ! Model 1 7 9 -TenkGau�ngtProbe:_� Model:ceor Vault Sensor. Modal_ E �3� b ulnr�ace or Vault Sensor Model• '79 -70ors�-Model: nM Zo t Sutn�/TrenchSensors : t Model: �a�Model: ' dl umpSensor s : Model 7993nicalLineLeakDetector. I Model: f ,P� u echanicalLineLeakDetector. jModel:nicLine Leak Detector Model: ' ectronic Line LeakDetector ! Model•Overfillllii -levelSensor. Model: 1Z9�395 ooI ankOvetfilllHi -levelSensor: Model•Specify equip.t e and model in Section E on Pa e 2 ether,Specffy Spec' a ui ,t e and model in Section E on PW 2 IfID: Tank M.enkGaugirt�ProbeModel ] 90/o n-Tank Gauging Probe: Model: uSQace or VaultSensor: Model: '79 3o/ Artnulars ace orVaultSensor ; Model:SumpJTrenchSenso__W: Model: 9 2a� sr SumplTrenchSensors : Model:SumpSensorSs�:— - ^-- _Model: ins umpSensor�s�__— —_; Madel ec_hanicaiLine Leak Detector. _Model: ! ZW.ovo echanicelLine Leak Detector. _i Model: e onic Line Leak Detector Model: Electronic Line Leak Detector _ j Model an_kOvedill/Htpi-levelSensor, Model ! ��i9S'd�e/ TnnkOverfill/High-levelSensor: I_Mo"l ! —_ Other,Spec' e .t e and model in Section Eon P e2 er,S ec' ee a and model in Section Eon PW 2 Dispenser ID:_—_ —"Z— Di enserID: 3— enserContain_mentSensors: ; Model:-; `9 enserContainment Sensot(s): Model: , heerValy s . _ haarVally s . —T— Dis enser Containment Flo! s and Ch!' s enser Containment Flo n s and Ch ' s Di ser ID: erID: 7- enserContainmentSensors: Model: nser Containment Senso s : I Model: hear Valves . heatValy s . enser Containment Flo! s and Ch!jn(sL er Containment Flo s and Ch!js DispensarID: _ DispenserID: It. spenserContainmentSensors: Model: is-enserContainmentSenso s _heerSh— .y is enserGantainmentFlo sendCh ' m s enser Containment Flo s and Ch ' s Vthe 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 fdeltijUd in this doeementwa inspected/urviced in accordance with the manufaetmis' guideHim. 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 wont For any a meat capable of generating such reports,I hoe also attached a cagy-of there�ortcheck all that apply}; _ stent set- _ histo ort Teehnieim!dem_e(Pring_ _-' Si agn tore:--_--- — _ -�--- certificationNo.. _ b 7 7 Y License No.: r'resting company Name: TAIT ENVIRONMENTAL SYSTEMS , Phone No.: 1 _'J14)560-8222 Page 1 of 3 03/O l