Laserfiche WebLink
MONITORING SYSTEM CERTEFICATION <br /> For Use By All Avisgliction3 WtWn the Mate of CaligwWa <br /> .&thorffy Cited:Chapter 6.7, J*a1th and S41Wy Code;Chapter 16,Division 3, 7Tt1e 23, Cal&rnia Code of Res <br /> This form must be used to document testing and servicing of monitoring equipment.A sjqy2k goijAgglig1k gj aggil mud be glegareg <br /> for 24ch meaLtgring Aystem conkgI.Yjad by the technician who performs the work. A copy of this form must be provided to the tank <br /> system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems whWA 30 <br /> days of test date. <br /> A. General Information <br /> FacilityName. ARCO PRODUCTS COMPANY Service Station No.: 12130 <br /> SiteKa�ii-ii.-IT90WWff DORADO ' STOCKTON Zips <br /> -Eaci4ty Contact Persom. t Phone No.: 9—IQ st q ;m j ------------- <br /> Date of Too emce: <br /> Make/Model of M <br /> B. Inventory of Equipment TestedlCertffied <br /> Check the=!MrUte bons to badicate=ific nopment iedfBe <br /> TankID: A Tank M: <br /> t3nugiraProbe: MR 2��Probe: Modal <br /> _Model: 4/0":? &Wtsensor Model- <br /> Lulmeirenchrenchsonsor(s): Model: <br /> Model 12940M aJOL <br /> Sonar—- Sensor(d): Model <br /> onical Line Leak Detector. Model al Line Leak Detector. Model: <br /> ctraaia Line Leak Detector T�Model:- ce�� Line Leak Detector Model:- C?-7 <br /> aaakOv Sensor OvedMO&-level Sensor Model:-_12��qqto* <br /> Othff6S cc&equip.type and model in Section Eon Page 2 Specify equip.type and model in Section E on Pw 2 <br /> T <br /> Teak <br /> W* <br /> act or V <br /> SUMPIT <br /> Sump <br /> a chankc <br /> ctronic <br /> c <br /> ctr <br /> jZ-7- <br /> .f05. 1eh <br /> ankG!u ' <br /> .jlpn Probe: -_'_Model: 41'>39LV6q n-Te4k Tnk Gauging Probe: Model:- -jb <br /> jr <br /> arS ace orVaiAtSensor: Model:_:_.159elwo<A0% adar§pace or Vault Sensor 1 Model: Ire <br /> tench Sensors Model: <br /> SumpTrench S Model- <br /> in Su <br /> Sul!!P.EeLljor Model: !;294 in Sump Sensor(s): A. <br /> Mode.. &2& <br /> calLine Look Detector. <br /> Model: i 0 amcal line Leak Dep!!ELoj..______�Mode1 <br /> ctrorai . 7- <br /> c Line Leak Detector 1 0 4ectronic Line Leek Detector i Model: <br /> ankOvetfsU/Higirlevel_Sensor: Ovetffiffigh-level Sensor: Model- 4 <br /> eca <br /> .j.!Ue and model in Section R on P 2Spac&jj 'p�. *,andmodel in Section E on Page 2 <br /> or M: <br /> Z— Didpgwer M: <br /> 07 <br /> sem_ <br /> onser C :erCC <br /> euvelve(s). t 02 <br /> h arVolv <br /> Dis PAns <br /> itaModol <br /> - -!a] --L- <br /> - onser Containment Flo MCO)andWair(s) enter Containment FloLKs)end2j�2Qs <br /> I - M2 i <br /> set ID: I Di onset M: <br /> am <br /> arContainment Sensors: Mo ercontainmentsen <br /> hear sneer Containment Flo! <br /> hs !�!�and Ch!!2�� i1spenser Containment Flo!g!)-arid chain(s) <br /> Dis <br /> -MU7-pensff Containment Sensors: Model:- i enser Containment Sonsots Edel: I <br /> _L�Sheaz Valve_(s)� <br /> fShe at V!tels). <br /> -jEE�jii�nt Flo <br /> !0 and sneer Containment FloLUO ands <br /> V the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at this facility. <br /> C. Cerdfication' -I cortify that the eqg4meitt idend&d in this&cwmntwu hmpected*evAced in accardame with,the nnauftftwl <br /> 9vIdelb" Attached to this Cerd&ofisn Is info(6-rw,man ufactaxero'checklists)necestaq to verify that this inbraaaden is <br /> cornet and a Flat Plans the layout of manitering ev*mapt. For any"!wnt capable of gene such report,jbageabo <br /> attached 9"of the!np±A(check all OW apply): - -040finset-jo jW4jW=hiSbryrWrt <br /> TechnicianNo <br /> Cerfficationft.: <br /> L— n'2-7 L/ License No.: <br /> Tcsrtingcompii�oR—�16--.,7 TAIT Rff WNUERTAL SYSTEMS Phon 6 No.: <br /> 560-M <br /> pop <br /> 1 of 3 til <br />