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►J q ONI RING SYSTEM CERTI ATION 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 Facility Name: ARCO PRODUCTS COMPANY Service Station No.: 2130 Site Address: 7906 N. EL DORADO STREET City: STOCKTON Zip: 95210 Facility Contact Person: ; I - 5 , (9;,L Contact Phone No.: _503- 2-3s/- 3 f5go Make/Model of Monitoring System: Date of Testing/Service: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific a ui ment ins ectad/serviced: Tank ID: Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: 01Gnular Space or Vault Sensor: Model:-r1 `3c,-4o0t L2Cnnular Space or Vault Sensor Model: 015iping Sump/Trench Sensor(s): Model: -224590 �ing Sump/Trench Sensor(s): Model: ?14j390 - Q(Fill Sump Sensor(s): Model: 9 4�3C: -�, ill Sump Sensor(s): Model: bm5phanical Line Leak Detector. Model: OMechanical Line Leak Detector. Model: 215fectronic Line Leak Detector Model: ER1ectronic Line Leak Detector Model: []Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other,SpecifZ equip.t e and model in Section E on Page 2 ❑Other,Specify equip. a and model in Section E on Page 2 Tank ID: Tank ID: ❑In-Tank Gauging Probe: Model: ❑In-Tank Gauging Probe: Model: Annular Space or Vault Sensor: Model:" 41`1j0i0-- -X' nnular Space or Vault Sensor M o d e 1:—/,,4n 11,/D--2 GOwing Sump/Trench Sensor(s): Model: t; wiping Sump/Trench Sensor(s): Madel: 9 41:N90 -zad' fi-vill Sump Sensor(s): Model: , ya _ Will Sump Sensor(s): Model•-)9 4.3'Y o ❑Me hanical Line Leak Detector. Model: ❑Me mcal Line Leak Detector. Model: lectronic Line Leak Detector Model: 95ectronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other,Specify equip. a and model in Section E on Page 2 ❑Other, Specify equip. a and model in Section E on Pa e 2 Dis er ID: 1- - J --ice Dispenser ID: is ser Containment Sensor : Model:-7�y , -Z� []Dispenser Containment Sensor(s): Model: hear Valve(s). ❑Shear Valve(s). ❑Dis eraser Containment Float(s)and Chain(s) []Dispenser Containment Floats and Chains Dispenser ID: Dispenser ID: ❑Dispenser Containment Sensors: Model: []Dispenser Containment Sensor(s): Model: ❑ Shear Valve(s). ❑Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s) ❑Dis enser Containment Float(s)and Chains Dispenser ID: Dispenser ID: []Dispenser Containment Sensors: Model: []Dispenser Containment Sensor(s): Model: ❑Shear Valve(s). ❑ Shear Valve(s). []Dispenser Containment Float(s)and Chain(s) []Dispenser 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;(check all that apply): ❑ System set-up ❑Alarm history re t Technician Name(Print): Signature: Certification No.: -3 7—d License No.: 588 098 Testing Company Name: TAIT ENVIRONME TAL SYSTEMS Phone No.: (714)560-8222 Page 1 of 3 03/01 Monitoring System Certification