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MONIWUNG SYSTEM CERTIF&TION <br /> use By All Jurisdictions Within the State of Calif <br /> Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3 Title 23, California Code of Regulations <br /> This form must be used to document testing and servicing of= equipment. If more than one monitoring system control panel is installed at the facility,a separate <br /> 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 <br /> system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. <br /> A.General Information <br /> Facility Name:-7-ELEVEN#32190(N-3810) MKT 2368 City: STOCKTON CA Zip:95206 <br /> Site Address: 4943 S.KINGSLEY(FRONTAGE RD) Contact Phone No: 939-0679 <br /> HWY 99 @ ARCH AIRPORT RD Date of Testing/Service: 12/01/2009 <br /> Facility Contact Person: MGR-LORENA <br /> Make/Model of Monitoring System:VR TLS 350 Work Order Number: 2270669 <br /> B.Inventory of Equipment Tested/Certified <br /> Check the appropriate boxes to indicate specific equipment inspected/serviced <br /> TanklD: 87 TanklD: 89 <br /> X In-Tank Gauging Probe. Model: MAG X In-Tank Gauging Probe. Model: MAG <br /> X Annular Space or Vault Sensor, Model: 302 Annular Space or Vault Sensor. Model: 302 <br /> 'XI Piping Sump/Trench Sensor(s). Model: 208 <br /> X Fill Sump Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: 208 <br /> Fill Sump Sensor(s). Model: 206 <br /> Mechanical Line Leak Detector. Model: <br /> PLLD Mechanical Line Leak Detector. Model: <br /> X Electronic Line Leak Detector. Model: RTankID:Electronic Line Leak Detector. Model: PLLD <br /> Tank OveMll/High-Level Sensor. Model: Tank Overfill/High-Level Sensor, Model: <br /> Other(specify equipment type and model in Section E on page 2). p type and model in Section E on page 2). <br /> Other(specify equipment <br /> TanklD: <br /> 71 In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: <br /> X Annular Space or Vault Sensor. Model: 302 Annular Space or Vault Sensor. Model: <br /> X Piping Sump/Trench Senors). Model: 208 Piping Fill Sump Sensogs). Model: 206 P 9 Sump/Trench Sensor(s). Model: <br /> X Fill Sump Sensor(s). Model: <br /> Mechanical Line Leak Detector. Model: <br /> X k Detector. Model: <br /> Mechanical Line LeaElectronic Line Leak Detector. Model: PLLD Electronic Line LeakDetector. <br /> Model: <br /> Tank Ovefill/High-Level Sensor. Model: <br /> Tank OverfilUHigh-Level Sensor. Model: <br /> Other(specify equipment type and model In Section E on page 2). Others eci <br /> ( p ty equipment type and model in Section E on page 2). <br /> Ispenser : 1/2 Dispenser ID: 3/4 <br /> ®Dispenser Containment Sensors) Model:208 X Dispenser Containment Sensors) Model:206 <br /> XJ Shear Valve(s). X Shear Valve(s) <br /> Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: Dispenser ID: 7/8 <br /> X❑Dlspenser Containment Sensor(s) Model:208 X Dispenser Containment Sensors). Model:208 <br /> X❑ Shear Valve(s). Shear Valve(s). <br /> Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats)and Chain(s). <br /> Dispenser ID: 9/10 Dispenser ID: <br /> 11/12 <br /> RX Dispenser Containment Sensors) Model:208 X Dispenser Containment Sensors). Model:208 <br /> X❑ Shear Valve(s). X Shear Valve(s). <br /> Dispenser Containment Floats)and Chain(s). ID Dispenser Containment Floats)and Cham(s). <br /> If the facility contains more tanks or dispensers,copy this forth. Include information for every tank and dispenser at the facility. <br /> C. Certification <br /> I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines. <br /> Attached to this certification is information(e.g manufacturers'checklists)necessary to verify that this information is correct. <br /> and a Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached <br /> a copy of the(Check all that apply): ❑System set-up Alarm history report <br /> Technician Name(print): BRYAN KEYS Signature: <br /> Certification No.: 833515 License.No.: 743160(Class'A'Genemi Enginerina Contractor License) <br /> Testing Company Name:Tanknology Phone No.:_(800)800-4633 <br /> Site Address: 11000 N.MoPac Expressway,suite 500,Austin,TX 78759 Date of Tesfing/Servicing: 12/01/2009 <br /> Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08 <br />