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MONIT�ING SYSTEM CE:RTIFWATION MAKE / MODE OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION / TEST DATE: October 17, 2011 Al. FACILITY A2. OWNER Name 7-Eleven Market#23681 Store#32190 Name 7-Eleven, Inc Address 4943 South State Route 99,Stockton,CA 95206 Address P.O.Box 711,Dallas,TX 75221 Phone# 209-939-0679 Phone# 805-523-2949 Contact Stephen Boyd Contact Stephen Boyd A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 600 E.Main Street,Stockton,CA 95202 Address P.O.Box 1025,W.Sacramento,CA 95691 Notified October 11,2011 Lic# 617238 A,B, Haz Inspector Muniappa Naidu Contact Dulcinea Covan Phone# 209-468-8257 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS Tank#1 (Product): Gasoline-87 Tank#2 (Product): Gasoline-89 ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794380-303 ■ Annular Space or Vault Sensor Model: 0794380-303 ■ Piping Sump I Trench Sensors) Model: 0794380-208 ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 _ ■ Fill Sump Sensors) Model: 0794380-208 ■ Fill Sump Sensor(s) Model: 0794380-208 ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ■ Electronic Line Leak Detector Model: 0848480-001 ■ Electronic Line Leak Detector Model: 0848480-009 ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank#3 (Product): Gasoline-91 Tank#4 (Product): ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794380-303 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump/Trench Sensors) Model: 0794380.208 ❑ Piping Sump/Trench Sensors) Model: ■ FIII Sump Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensors)l Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ■ Electronic Line Leak Detector Model: 0948480-001 ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: E12: DISPENSERS/UDC's Dispenser#: 1-2 Dispenser#: 3-4 ■ Dispenser Containment Sensor(s) Model: 0794380.208 ■ Dispenser Containment Sensors) Model: 0794360-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s)and Chains) L❑ Dispenser Containment Float(s)and Chains) - - Dispenser#: 5-6 Dis7Dispenser 7-8 ■ Dispenser Containment Sensors) Model: 0794380-208 ■ ent Sensors) Model: 0794380-208 ■ Shear Valves ■ ❑ Dispenser Containment Float(e)and Chains) ❑ ent Float(s)and Chains) Dispenser#: 9-10 Dispenser#: 11-12 ■ Dispenser Containment Sensor(s) Model: 0794380.208 ■ Dispenser Containment Sensors) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Floats)and Chalri ❑ Dispenser Containment Floats)and Chahl 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 verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report; (check all that apply): ■ System set-UP ■ Alarm History Report WALTox Signature: ENGINEERING,INC. Technician/Cert#: Jessie Watkins/B35391 5307886-UT Date: October 17,2011 0 2011 Walton Engineering,Inc.