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For Use Ar All Jurisdictions Wthin the ShWe of Call'jornia <br /> Adhon&Cited:Chapter 6.?,Health and Sd Code;Chapter 16,Division 3, Title 23, Calornia Code of JUgulations <br /> Tl is form mustbe used to document teding end servicing ofmonitoting equipment.A j29K&U cextificatioa a�igEo:t musf be vra azect <br /> far j1da m2nd2jing lyd&m gautmj penal by the technician who petforms the work. A copy of this form must be provided to the tank <br /> system ownedoperator. The ownedoperator must submit a copy of this form to the local agency regulating systems Wmin 30 <br /> days of test dote. <br /> A. General Information <br /> ..Facility Name_; ARCO PRODUCTS COMPANY _ ! ! Service StationNo.: <br /> _Site Address: L2430 JOE POMBO PKWY- j Cites 'CR YC � .—195376 <br /> FacilitgContact Person:1: O�hw, � �..-�' _ � Contact Phone No.. <br /> Make/Model.� ofMonito System i VI? ?G S 3:3� - ^� Date of Tee� Service:Y'1 <br /> B. Inventory of Equipment Tested/Certified <br /> Check the M=riata boxes to hodicate 2wific egkmrat tMetedJ <br /> Tactic ID: i Tank ID: s. L <br /> Tank Probe: i Model- TankOa ' Probe: Model: <br /> ace orV'aultSew or: ! Model: g ar ac ofVaultSensor Model: �n MO- <br /> S ranch Sensor(a):�V�Modal reneh Sensors : Model: : 7 <br /> all Sensor s : Model S Sensors : _ ! Model 79 �. ' <br /> achaniealUm Leek Detector. ; Model eehanicalLine Leak Detector. 1 Model: <br /> octranic Line Leak Detector Madel ctmraic Lino Leak Detector _; Model . <br /> enk(?v levolSenaor Madel ! th► _ level Sensor- ` Modal <br /> #hatftecift eg&jae and model inSection E on Pa e %or,Sgecifir equip.type and model inSection E onPage 2� <br /> Tank ID: T ID: <br /> ffln-Tank(Muging Probe: ; Model Tank Frobe: _ 1 Model:- <br /> ace <br /> odel:ace orVaWtSensor.F Model nnularS ace orVaultSensor i Model ° <br /> S rene4Sensors :— Model 7 S /Trench Sensors : �' Model: <br /> illSum�Sansot a _ Model: 29 d1S Sensors): Model: <br /> echarricalLine Leak Detector. Model ac 'c al Lino Leak Detector. Model: <br /> Line Look Detector Model: a CUM <br /> line Leak Detector ; Model: <br /> ankOv ' levelSanaor: i Model: LOve level Sensor: Model:- <br /> ' <br /> oca e and model inSection E on P e t S ec' equip.type and model in Section Eon PaLe 2 <br /> eraser ID: user m• <br /> OnferContaimentSensors:_; Model '79y le- onset ContainmentSenso s :_ _ lNlodal: <br /> eaValv!QsT� <br /> eraser Containment Flo s and s penser Containment Flo!Ss and ' s <br /> arm: D' ensof ID: - — <br /> enserContainment Sensors: Model ezC entSena so:��: A1Iada1: �94,- 7 <br /> aes6►eavo s . — �- __'_______. oarValva a . <br /> enser Containment Flo s and s enser Contaizaent Flo!!W and Chain(s)W� <br /> Exomeas"rz <br /> t ID: t /-) Dia set M: <br /> serContainmentSensors: a Model: ;?9 enserC entSansot>_s : Madel 4� <br /> ser Containment Fla s end Ch ' s onset C ent Flo s and Ch ' a :Lj <br /> *If the facs'Zity contains more tanks or dispensers,copy this form.. Inckule information for every tank and lisp eraser at this facility. <br /> C. Ce cation-Icerft fttIcethe eqvdpwat WMKed fa this dommatwasis stwordance with the mmifickwus' <br /> gddeftw. Attack"to Ols Cerd&a&R is ' n(64r,wasufacturen'chechHoft)Westaxy to Verify that ads inbralation U <br /> correct and a Plot Plan sh9wing the h1put of mnitering equjpxwmt For any WjpMent Capable of genentift suk nporh6 I hasalm <br /> attathed a M of the •(rte eFatck d appt set <br /> Technician Name <br /> Certification No. _ i License No. ..p i <br /> Testing Compagy Nemo: TAIT ENVIRONNUENTAL SYSTEMS I Phone No,: Q14)5W222 <br /> Fsplef3 03x1 <br />