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O NG SYSTEM CERTIOCATION 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 Service Station No.: Site Address: % j t' L ✓. t—/�G�i�'L�h—� City: S4t�- o Zip: Facility Contact Person: � art n �>c 1�`7T.�� Contact Phone No.: �P �� 3-1 55 -- Make/Model of Monitoring System: �L �St, Date ofTesting/Service: B. Inventory of Equipment Tested/Certified Check the appr2griate boxes to indicatespecific equipment ins ected/serviced: Tank ID: i, Tank ID: _S ❑In -T nk Gauging Probe: Model: []In -Tank Gauging Probe: Model: .lar Space or Vault Sensor: Model: 440.11 )anular Space or Vault Sensor Model: Lc� 5 iping Sump/Trench Sensor (s): Model: 2 0 9 wiping Sump/Trench Sensor (s): Model: :2 c> ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: BElectronic Line Leak Detector Model: C_ 0::C ❑Electronic Line Leak Detector Model: []Tank Overfill/High-level Sensor: Model: []Tank Overfill/High-level Sensor: Model: ❑Other, Specify a ui a and model in Section E on Page 2 ❑Other, Specify a ui . e and model in Section E on Pae 2 Tank ID: 0,2 Tank ID: ❑In -Tank Gauging Probe: Model: ❑In -Tank Gauging Probe: Model: Q'Knnular Space or Vault Sensor: Model: =lo []Annular Space or Vault Sensor Model: EP[ping Sump/Trench Sensor (s): Model: a v - []Piping Sump/Trench Sensor (s): Model: ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: EIM55jhanical Line Leak Detector. Model: []Mechanical Line Leak Detector. Model: lectronic Line Leak Detector Model: C to .7 []Electronic Line Leak Detector Model: ❑Tank Overfill/High-level Sensor: Model: ❑Tank Overfill/High-level Sensor: Model: ❑Other, Specify a ui a and model in Section E on Page 2 ❑Other, S ecif aqui a and model in Section E on Page 2 Dispe er ID: — Dispenser ID: 3—�{ is user Containment Sensors: Model: "Zc�� — 06i enser Containment Sensor(s): Model: Zoe' 9-9hear Valve(s). hear Valve(s). ❑Dis enser Containment Floats and Chains ❑Dis enser Containment Floats and Chain s) DOenser ID: Dispenser ID: [!DKP enser Containment Sensors: Model: -27�d— penser Containment Sensor(s): Model: Z_ e_> Shear Valve(s). Shear Valve(s). ❑Dis enser Containment Float(s and Chains ❑Dis enser Containment Floats and Chain(s) 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) ❑Dis enser Containment Floats 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 eqm nt. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): 0 System set-up rm histor�t report Technician Name (Print): Craig Block Signature: %� Certification No.: 73 License No.: 5,38--69-8 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (916) 858-1090 Page I of 3 03/01 Monitoring System Certification