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MONIT NG SYSTEM CERTIFICTI4N By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,HeM and Safety Code;Chapter 16, Division 3 Title 23, a rnia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,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 ownerloperator 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: 7-ELEVEN#14117,MKT 2368 City: STOCKTON CA Zip:95204 Site Address: 2725 COUNTRY CLUB BLVD Contact Phone No: 463-1259 Date of Testing/Service: 0312412010 Facility Contact Person: MANAGER-GIL Make/Model of Monitoring System:TLS 350R Work Order Number: 2273297 B.Inventory of Equipment TestedlCertified Check the appropriate boxes to indicate specific equipment inspected/serviced TanklD: 91 TanklD: 87 X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe, Model: MAG X Annular Space or Vault Sensor. Model: 420 X Annular Space or Vault Sensor. Model: 420 X Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model; Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank Overfill/High-Level:Sensor. Model: FILAPPERIEXTERNAL ALARM Tank Overfill/High-Level Sensor. Model: FLAPPER/EXTERNAL ALARM Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). TanklD: TanklD: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: Piping Sump/7rench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank OverfilllHigh-Level Sensor. Model:. Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). Dispenser : 112 Dispenser ID: ®Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s) Model: Q Shear Valve(s). Shear Valve(s) ElDispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser lD: Dispenser lD: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: FShear Valve(s). Shear Valve(s). 11 Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser lD: Dispenser lD: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). Shear Valve(s), 0 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 the 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, l have also attached a copy of the(Check all that apply): System set-up Alarm history report r Technician Name(print): STEVEN WILLEMS Signature: Certification No.: B36743 License.No.: 743160(Class'A'General Enginering Contractor License) Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 11000 N.MoPac Expressway,suite 500,Austin,TX 78759 Date of Testing/Servicing: 0312412010 Monitoring System Certification Page 1 of 3 Based on CA form dated 03108