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MONITORING SYSTEM CERTIFICATION Fo y All Jurisdictions Within the State of CallIft Authority Cited: Chapter 6.7,HealWWd Safety Code; Chapter 16,Division 3, Titl , 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: Contact Phone No.: ( LTJ Make/Model of Monitoring System: i 11�zb %(,5:!5b Date of Testing/Service: Iq�VK53 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s ecific equipment inspected/serviced: Tank ID: Tank ID: ❑In-Tank Gauging Probe: Model: []In-Tank Gauging Probe: Model: MAnnular Space or Vault Sensor: Model: of PAnnular Space or Vault Sensor Model: c)-gCe Piping Sump/Trench Sensor(s): Model: '?q 2Ci:K f4Piping Sump/Trench Sensor(s): Model: Will Sump Sensor(s): Model: ?9u3$c7 Zv DiFill Sump Sensor(s): Model: Tto-2.61 Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: AElectromc Line Leak Detector Model: ❑Electronic Line Leak Detector Model: ,1Tank Overfill/High-level Sensor: Model:Q-Sc>_yioe46VR JMTank Overfill/High-level Sensor: Model:GtSO-A-ttCy j6V2 ❑Other,S eci equip. e and model in Section E on Page 2 ❑Other,S eci e!!! a and model in Section E on Page 2 Tank ID: Tank ID: 411 []In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe: Model: Annular Space or Vault Sensor: Model: IN Annular Space or Vault Sensor Model: Piping S /Trench Sensor(s): Model:-1g(4111-7DModel: -� ,MFill Sump Sensor(s): Model:'I4L4 . Fill Sump Sensor(s): Model:-19 LjjW�? ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: []Electronic Line Leak Detector Model: j4Electronic Line Leak Detector Model: JMTank Overfill/High-level Sensor: Model:GI So-u to,_10 L RTank Overfill/High-level Sensor: Model:G(-,0-AtaC./6Vzz_ ❑Other,SEecify a ui . e and model in Section E on Page 2 ❑Other,Sgecify equip. a and model in Section E on Page 2 Dispenser ID: (4i, Dispenser ID: '-Z•t .RDispenser Containment Sensors: Model: `toy A]Dispenser Containment Sensor(s): Model: "7ri�i3SC0-Z,4 -k Shear Valve(s). .�J Shear Valve(s). ❑Dis enser Containment Floagsj and Chain(s) QDisj2enser Containment Floats and Chain s Dispenser ID: �3_Kf Dispenser ID: .lP�IDispenser Containment Sensors: Model: ' qct ❑Dispenser Containment Sensor(s): Model: ,( Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Floats and Chains ❑Dis enser Containment Floats and Chain(s) Dispenser ID: ( _ Dispenser ID: JNDispenser Containment Sensors: Model: j ❑Dispenser Containment Sensor(s): Model: Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats)and Chain(s) E]Disj2enser 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 ap O): ®System set-up 0 Alarm history report Technician Name(Print): rl 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