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MONIT NG SYSTEM CERTIFI TION e 8y Afi Jurisdictions Within the state of Caiifom er 6.7 H�nd safety code,Chapter i 6, Division 3 Title 23, C r omia Code of Regulations Authority Cited:Chapter , 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 facitity,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 ownerloperator. 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 CA Zip:95204 Facility Name: 7-ELEVEN#114117,MKT 2368 City: St Phone No: 463-1259 N Site Address: 2725 COUNTRY CLUB BLVD Contact Phone Date of Testing/Service: 0411812008 Facility Contact Person: MANAGER-GIL Make/Model of Monitoring System:TLS350 Work Order Number: 2256172 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced rAnnular Tank ID: PREM Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG r Vault Sensor. Model: 420 Annular Space or VaultSensor. Model: 420 nch Sensor(s). Model: 352 Piping SumplTrench Sensor(s). Model: 352 Fit]Sump Sensor(s). Model Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD2000 FXiV -( X Mechanical Line Leak Detector. Model: Electron'c Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-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). Tank ID: TanklD: In-Tank Gauging Probe. Model: In-Tank Gauging Probe, Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping SumplTrench Sensor(s). Model: Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical tine Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector.. Model: Tank OverfilllHigh-Level Sensor. Model: Tank Overfill/High-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 : 1!2 Dispenser ID: FRIDispenser Containment Sensor(s) Model. 208 Dispenser Containment Sensor(s) Model: X❑Shear Valve(s). Shear Valve(s) Dispenser Containment Float(s)and Chain(s). Dispenser Goniainment Floai(s)and Chain(s). Dispenser lD: Dispenser ID: ) Model: Dispenser Containment Sensor(s). Model: F]DispenserContainment Sensor(s Shear Valve(s). Shear Valve(s), Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser lD: DispenserlD: Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). 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 manufacturersguidelines. 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,I have also attached a copy of the(Check all that apply): ❑System set-up 0 Alarm history report Technician Name(print): RHOM E DESBIENS Signature: Certification No.: 1938 License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N. MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 04118/2008 Page 1 of 3 Based on CA form dated 03101 Monitoring System Certification