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MONITORING SYSTEM E TIFI N For Use Bir All Jurisdictions 94thin the nate 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 Facilit Name: ! ARCO PRODUCTS COMPANY_..__ A� _ --_ ; Service StationNo. ;2093 Site Address: ,3425 TRACY BLVD City TRACY Zip: 95376 Facilit _.Facili y_-__ _ . NN .SHOT-7`�7Z_ Contact Phone No.: Contact Person: ,�6 9 yy_ 333 • Make/Model ofMonitoring System �/ /L -rt_ -_3S0 Date of TestrngJServrce i ,� d E. Inventory of Equipment Tested/Certified Check the Rpnpriate boxes to indicate specific a next! ected/servi,ced: Tank ID: 7 T D: X75 T ank Gauging -- !Model: $47 yo- 0 7 n-TankGaug�ngProbe: ; Model: f�1I 3yo -`6 arSpace or Vault Sensor Model: - �9�I3y®_ o� ularSpace or Vault Sensor Model: �y�1,3vQ-yrsy Sump/TrenchSensor�s) Model: 75ya� nchSensorModel: 7iv38� X308 Sensor�s� Model7 y38o-s�7v8ill SumpSensor(s)- Model: 71{nrcalLineLeakDetector E Model: Mechanical Line Leak Detector. i Model:-- nic Line Leak Detector ,` Model: PG.C11 onic Line Leak Detector Model: verFilllHrgh level Sensor ;-.Model + 79oo9r -tel ankOverfill/Hrgh level Sensor 1 Model 7yoo9i -ccv a ui .t e and model in Section E on Pa e 2 they,Specify equip.t e and model in Section E on Page 2 T ID: 7 S Tank c fill - ankGaunProbe: _ -Model: QN739C-/o n- ,ankGaungProbe - Model: y7, qp-/D nnularSpace orVauttSenso ., Model: 79y390 WF arSpace or Vault Sensor Model: 79W34o -y err r.Sum /Trench Sens ors j Model:-, 79V3gc,-,gg r ' Sum /Trench Sensor s) j Model 7*eI3,, fie) g SumpSernsor s . —�� Model: -7��3 ) -.aog Sum Sensors : Model: x9413 3e.ti-aog echanicalLine Leak Detec_tor ; Model:- c hanicalLine Leak Detector - `Model: e onic Line Leak Detector Model: a onic Lina Leak Detector j_Model: Pe-I-A ankOverfillf hlevelSen_sor Model: ' 7900_91 No17 ankOverfill/HighlevelSensor:_ i Model 7_4_0091_-_eao,�_ ther,S2ecify equip.t e and model in Section Eon Page 2 tiler,Specify equip.t e and model in Section E on Page 2 _ Dis enser ID: Ij Dis eraser ID: 41 enser Containment Sensors:_F Model_'7, 3 - .2o s enser ContainmentSensor(s). Model: �/3Se-AO hear Valves hear Valves . rs enserContainmentFloa s and Ch ' s Dispenser enser ContainmentFloa s and Chain(s) Dis nserID: S' Dis ser ID: 7 ---- -_ penserContainmentSensors Model: 9'13 S enserContainmentSensor(s): Model. *7 j�•z o8 __ ShearVsl�e s _ - _ _ _--_. __._. —_-_-- �� ----_ _ ShearValve�s) bisp ens erContainmentFlo a s and Chain(s) Dis enser ContainmentFloa s and Ch ' s If5er ID: Dispenser ID: erContainmentSensors. Model: ispenserContainmentSensor(s): Model: alve(s). She ar V alve(s).C ontain went Flo As) and Chain(s) is enser Containment Float(s) and Ch ' 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 documentwas inspected/serviced in accordance with the manufachaers' guidelines. Attached to this Certification is information(e.'g. ufuturers'checklists)necessary to verify that this information is correct and a Plot Plan shoving the layout of monitoring e ment For any a went capable of generating such reports,I hmeake attached,a copy of the report; (check all that.app�): System set-up Alarm history resort Technician Name(Priv . y ilo 10wOU SON Signature: P Certification No.: OOb -oS- 0317 License No.: 3 13-bg Testing CompanyName: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page 1 of 3 03101