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p. MONITAING SYSTEM CERTIFIC 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 pr_pe ared 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 Facility Name: ARCO PRODUCTS COMPANY Service Station No.: 2093 Site Address: 3425 TRACY BOULEVARD City: TRACY Zip: Facility Contact Person: C h it 12 4-Q ck Contact Phone No.: 5U L 63 / Make/Model of Monitoring System: �1.L I Le,/1 x �](� Date of Testing/Service: B. Inventory of Equipment Tested/Certified Cheektheap o riate boxes to indicate specific equipment ins acted/serviced: Tank ID: / / Tank ID: 47 []In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: Annular Space or Vault Sensor: Model: L [ Annular Space or Vault Sensor Model: RPiping Sump/Trench Sensor(s): Model: L..5 CoPiping Sump/Trench Sensor(s): Model: (Fill Sump Sensor(s): Model: S3 OFill Sump Sensor(s): Model: ❑Mechanical Line Leak Detector. Model: []Mechanical Line Leak Detector. Model: 14Electronic Line Leak Detector Model: G ❑Electronic Line Leak Detector Model: []Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: []Other, Specify equip. e and model in Section E on Page 2 ❑Other,Specify e ui . e and model in Section E on Pa e 2 Tank ID: Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: Annular Space or Vault Sensor: Model: L:S QAnnular Space or Vault Sensor Model: RPiping Sump/Trench Sensor(s): Model: f ®Piping Sump/Trench Sensor(s): Model: KFill Sump Sensor(s): Model: 1—S ®Fill Sump Sensor(s): Model: - [@Mechanical Line Leak Detector. Model: J v ( 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,S eci equip. a and model in Section E on Page 2 ❑Other,Specify aqui a and model in Section E on Pa e 2 Dispenser ID: :L- Dispenser ID: _— []Dispenser Containment Sensors: Model: []Dispenser Containment Sensor(s): Model: aShear Valve(s). [�j Shear Valve(s). []Dispenser Containment Float(s)and Chain ❑Dis enser Contairanent Floats` and Chain(s) Dispenser ID: — Dispenser ID: —? []Dispenser Containment Sensors: Model: ❑Dispenser Containment Sensor(s): Model: Shear Valve(s). 14 Shear Valve(s). ODispenser Containment Floats and Chains ❑Dis enser Containment Float(s)and Chain(s) Dispenser ID: n Dispenser ID: ` -- []Dispenser Containment Sensors: Model: — ❑Dispenser Containment Sensor(s): Model: Shear Valve(s). 0� Shear Valve(s). ❑Dis enser Containment Float(s)and Cha!ELsL ❑Dis enser 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 monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report;(chck 1 that apply): ❑ System set-up ❑ Alarm history repo t Technician Name(Print): /7 �t,,,- J,j,-).r,�?�, Signature: =-- Certification No.: License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714)560-8222 Page 1 of 3 03/01 Monitoring System Certification