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8-22-07;10:23AM;SACRAMENTO EMC ;916 925 2816 h A— _ <br />MONITORING SYSTEM CERTIFICATION <br />For Use by All Jurisdiotione Within the State of California <br />Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations <br />This fort must be used to document testing and servicing of monitoring equipment A separate certification or report must be prepared for each monitoring system control <br />panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator mus[ submit a copy of We <br />form to the local agency regulating UST systems wtthing 30 days of test date. <br />facility Name <br />7/11 <br />Bldg No. <br />32190 <br />Site Address: <br />4943 Snout State Route 99 <br />City: <br />Stockton <br />Zip <br />95602 <br />Facility Coolant Person: <br />Contact Phone No.: <br />209-939-0679 <br />Make/Model of Monitoring System: <br />TIS- 350/ SNO A0369068905001 <br />Date of Testing/Servicing: <br />08-21-07 <br />....,, v. r -y nweu <br />r`6nrL11.n e....m...: _... M..........—J:_a <br />Tank ID: Tl- (91) <br />Model <br />Tank E): T2- <br />Model <br />In -Tank Ganging Probe <br />B <br />Io -Took Gauging Probe <br />B <br />Tank Annular Space or Vault Sensor <br />A <br />'Lank Annular Space or Vault Sensor <br />A <br />Piping Sump / Trench Sensor(s) <br />P <br />Piping Sump / Trench Smsor(s) <br />P <br />Fill Sump Smaor(s) <br />H <br />Fill Smnp Sensors) <br />H <br />Mechanical Line Leak Detector <br />M <br />Mechanical Line Leak Detector <br />M <br />1 <br />Electronic Line Leak Detector i31C' <br />E <br />848480-001 <br />Electronic Line Leak Detecror <br />E <br />Tank 0,afil1/High-level Sensor <br />T <br />Tank OmrillUfkgh-Level Sensor <br />T <br />Piping Sump Secondary Containment Senor <br />K <br />Piping Sump Semndary Contairmneet Sensor <br />K <br />rill Sump Secondary Containment Sensor <br />K <br />Fill Sump Secondary Containment Senior <br />K <br />Product Line Secondary Containment Senor <br />W <br />Product Line Secondary Containment Sensor <br />W <br />Van Line Secondary Containment Sensor <br />W <br />Vent Line Secondary Containment Senor <br />Other (specify equipment type and model in Semm E m Page 2) <br />Other (specify equipmaV type and model m Section E en Page 2) <br />Tankm: T3 <br />Model <br />Vent Sump: <br />Model <br />In -Tank Gauping Probe <br />B <br />Vent Piping Sump Sensor <br />P <br />Annular Spam ar Vault Sere" <br />A <br />Vent Sump Secondary Comtairmtent Sensor <br />K <br />Piping Sump / Trench Senor(s) <br />P <br />Fill Sump Senor(s) <br />H <br />Vapor Remvery Line <br />Mechanical Line Leak Datecmr <br />M <br />Vapor Rerun Secondary Containment <br />W <br />Electronic Line Leak Detector <br />E <br />Tank OverSNHigh-level Sensor <br />T <br />Piping Stmrp SecondaryContairmrent Senor <br />K <br />Fill Sump Secondary Containment Sensor <br />K <br />Product Line Secondary Containment Senor <br />W <br />Ver Line Secondary Containment Sensor <br />W <br />Other (,it* eqaipment type oul model in Section E on Page 2) <br />C. CetiiflnHon -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guideknes. Attachedto thus <br />Certification is information (e.g. manufact rrers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring <br />equipment. For any equipment capable of generating such reports, i have also attached a copy of the (check all that apply): <br />System set-up report (attached) AI (attached) <br />Technician Name (print): Signature: <br />Certificate: l fI Cnntrnnt 1 f- se Nn —I_ 7377 <br />Testing Company Name: Sacramento Equipment Maintenance Com any, Inc. Phone No. 916-925-2716 Work Order # 126656 <br />03/01 comity/00009statell-mon7oringcertwpd Page 1 of 6 <br />