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MONITORING SYSTEM CERTIFICION Folft By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7, HeAW d Safety Code;Chapter 16,Division 3 Title 23, Ca . to 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 ownerfoperator. 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: 0212412011 Facility Contact Person: MANAGER-GIL Make/Model of Monitoring System:VEEDER ROOT Work Order Number: 2279646 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: T1-91 PREME Tank ID: T2-87 REG X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor, Model: 402 X1 Annular Space or Vault Sensor, Model: 402 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: X Mechanical Line Leak Detector. Model: FXi V X Mechanical Line Leak Detector. Model: LD2000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank OverfilllHigh-Levet Sensor. Model: EA Tank Overfilt/High-Level Sensor. Model. EA 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: Tank ID: In-Tank Gauging Probe. Modek: 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/Trench 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 Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Secticn E on page 2). Dispenser : 112 Dispenser ID: ®Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s) Model: Shear Valve(s). Shear Valve(s) Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chair(s). Dispenser ID: Dispenser 10: F]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). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). F7 Shear Valve(s). EDispenser 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, l have also attached a copy of the(Check ail that apply): ®System set-upXI Alarm history report Technician Name(pant): JULIAN TILLMAN Signature: Certification No.: b39371 License.No.: 743160(Class'A'General Enginering Contractor License) Testing Company Na me:Tanknology Phone No.: (800)800-4633 Site Address: 11000 N.MoPac Expressway,suite 500,Austin,TX 78759 Date of Testing/Servicing: 02/24/2011 Monitoring System Certiticationl Page 1 of 3 Based on CA form dated 03108