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' MONI�&NG SYSTEM CERTIFI TION 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 FEB 2 6 2003 Facility Name: ARCO PRODUCTS COMPANY Service Station No.: 6080 ENVIROWENT HEALTH Site Address: 85 E.Louise Avenue pF{�q,��7;�Fq}}3�S Lathrop Zip: 95330 Facility Contact Person: CbTtrivtnTlt 1o�^r- S ? Contact Phone No.: (593} 34-38 9' 262-GO -3335 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Service: 12/16/02 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 87 Tank ID: 89 ❑In-Tank Gauging Probe: Model: []In-Tank Gauging Probe: Model: ®Annular Space or Vault Sensor: Model: 794380-302 ®Annular Space or Vault Sensor Model: 794380-302 ®Piping Sump/Trench Sensor(s): Model: 794380-208 ®Piping Sump/Trench Sensor(s): Model: 794380-208 [-]Fill Sump Sensor(s): Model: I ❑Fill Sump Sensor(s): Model: EMechanical Line Leak Detector. Model: LD-2000 ®Mechanical Line Leak Detector. Model: LD-2000 []Electronic Line Leak Detector Model: []Electronic Line Leak Detector Model: ETank Overfill/High-level Sensor: Model: EWA1100-057 ETank Overfill/High-level Sensor: Model: EWA1100-057 EOther, S2eciEy eSuip.jMe and model in Section E on Pa e 2 EOther, S eci equ!2.IMe and model in Section E on Page 2 Tank ID: 91 Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: EAnnular Space or Vault Sensor: Model: 794380-302 ❑Annular Space or Vault Sensor Model: EPiping Sump/Trench Sensor(s): Model: 794380-208 []Piping Sump/Trench Sensor(s): Model: ❑Fill Sump Sensor(s): Model: ❑Fill Sump Sensor(s): Model: EMechanical Line Leak Detector. Model: LD-2000 []Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector Model: []Electronic Line Leak Detector Model: ETank Overfill/High-level Sensor: Model: OPW 61SO 410 []Tank Overfill/High-level Sensor: Model: EOther, Specify equip. a and model in Section E on Page 2 ❑Other,Specify equjE.jae and model in Section E-on Page 2 Dispenser ID: 1+2 Dispenser ID: 7+8 EDispenser Containment Sensors: Model: 794380-208 EDispenser Containment Sensor(s): Model: 794380-208 E Shear Valve(s). E Shear Valve(s). []Dispenser Containment Floats and Chains ❑Dis enser Containment Floats and Chain s Dispenser ID: 3+4 Dispenser ID: EDispenser Containment Sensors: Model: 794380-208 []Dispenser Containment Sensor(s): Model: E Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s) ❑Dis enser Containment Floats and Chain(s) Dispenser ID: 5+6 Dispenser ID: EDispenser Containment Sensors: Model: 794380-208 []Dispenser Containment Sensor(s): Model: E Shear Valve(s). ❑Shear Valve(s). ❑Dis enser Containment Floats and Chain(s) []Dispenser 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 eq i ment capable of generating such reports,I have also attached a copy of the report;(check all that apply): ,�System set-up Alarm history report Technician Name(Print): STEVE SWEATT Signature:JJJ Certification No.: 3666 License No.: 588 09 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (916)858-1090 Page 1 of 3 03/01 Monitoring System Certification