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MONITANG SYSTEM CETIFIC ON 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 r �>� for each monitoring system control panel by the technician who performs the work. A copy of this form must �h�t `� 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. NOV 0 4 200z A. General Information ENVIRON ENT HEALTH Facility Name: ARCO PRODUCTS COMPANY Service Station No.: 5450 nrnLMT/grLtilyllAGES Site Address: 1617 W FREMONT City: STOCKTON Zip: 95203 Facility Contact Person: L} -/P_ I S Contact Phone No.: __5_0 3 ' -Z3 2' d Make/Model of Monitoring System: 1-" -JS6 Date of Testing/Service: / 0_2 B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 7 Dln-Tank Gauging Probe: Model: Tank ID: P -7S DIn-Tank Gauging Probe: Model: [Annular Space or Vault Sensor: Model: -7-1y 9c` - yc Space or Vault Sensor Model: ? 90 -go S [ iping Sump/Trench Sensor (s): Model: y t3 o - ' ,, �K,,�rnnnular I.71'�ping Sump/Trench Sensor (s): Model: -79 y ❑Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: DM chanical Line Leak Detector. Model: W DMechanical Line Leak Detector. Model: (electronic Line Leak Detector Model: C ❑Electronic Line Leak Detector Model: DTank Overfill/High-level Sensor: Model: 2 ❑Tank Overfill/High-level Sensor: Model: pother, S eci a ui a and model in Section E on Pa e 2 DOther, S eci equip. t e and model in Section E on Pa e Tank ID: DIn-Tank Gauging Probe: Model: Tank ID: DIn-Tank Gauging Probe: Model: ranular Space or Vault Sensor: Model: 71v3 -f® --,,/c,-7 ❑Annular Space or Vault Sensor Model: `ping Sump/Trench Sensor (s): Model: 77e-i_�80 - []Piping Sump/Trench Sensor (s): Model: ®Fill Sump Sensor (s): Model: ❑Fill Sump Sensor (s): Model: Dhanical Line Leak Detector. Model: DMechanical Line Leak Detector. Model: lectronic Line Leak Detector Model: L -]Electronic Line Leak Detector Model: DTank Overfill/High-level Sensor: Model: 2 ❑Tank Overfill/High-level Sensor: Model: ❑Other, Specify a ui a and model in Section E on Pa e 2 ❑Other, Specify equip. t e and model in Section E on Page Dis,Renser ID: I 1LDis nser ID: 3"-/ QD9 penser Containment Sensors: Model: i,2� &i- 08 is enser Containment Sensor(s): Model: 7�y3 Valve(s). hear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) ear []Dispenser Containment Float(s) and Chains D�i�s nser ID: 5- 0 L.D-»S enser Containment Sensors: Model: 7yy3&� :Zo Dispenser ID: 7� S L9is enser Containment Sensor(s): Model � 3 -.Z n EL hear Valve(s). [dear Valve(s). ❑Dis enser Containment Float(s) and Chain(s) DDis enser Containment Float(s) and Chain(s) Dis nser ID: is en Containment Sensors: Model: i Dis nser ID: Misiam is enser Containment Senso s): Model: Valve(s). ear Valve(s). DDisenser Containment Float(s) and Chain(s) Shear []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 For any equipment capable of generating such reports, I have also correct and a Plot Plan showing the layout of monitoring equipment. attached a copy of the report; (chSo all that apply): System set-up OAlarm history repo Technician Name (Print): % ,_0 e`>•✓e Signature: Certification No.: �/ - /P3 License No.: 588 098 Testing Company Name: TAIT ENVIRONMENTAL SYSTEMS Phone No.: (714) 560-8222 Page 1 of 3 03/01 Monitoring System Certification