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MONITNG SYSTEM CERTIFITION e By A!! Jurisdictions Within the State of Cali/omi Authority Cited., Chapter 6.7, He and Safety Code,, Chapter 16, Division 3 Title 23, mis 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 foreach monitoring system control Panel by the technician who performs the work. A copy of this form must he provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating OST systems within 30 days of test date. A. General Information Facility Name: 7 -ELEVEN #32190 (N-3810) Site Address: 4943S. KINGSLEY MKT 2237 Facility Contact Person: MGR - LORENA Make/Model of Monitoring System:V/R TLS 350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: STOCKTON CA Zip: 95206 Contact Phone No: 939-0679 Date of Testing/Service: 01/17/2007 Work Order Number: 2246805 Tank ID: 87 Tank ID: 89 71 In -Tank Gauging Probe, Model: MAG -1 X In -Tank Gauging Probe. Model: MAG -1 X Annular Space or Vault Sensor. Model: BRINE Annular Space or Vault Sensor. Model: BRINE 71 Piping Sumprrrench Sensor(s). Model: 208 Piping Sumpfrmnch Sensor(s). Model: 206 X Fill Sump Sensor(s). Madel: 208 206 Mechanical Line Leak Detector. Model: Fill Sump Sensor(s). Madel: X Electronic Line Leak Detector. Model: PLLD Mechanical Line Leak Detector. X Model: Electronic Line Leak Detector. model: PLLD 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: 91Tank ID: In -Tank Gauging Probe. Model: MAG -1 In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: BRINE Annular Space or Vault Sensor. Model: X Piping Sumprrnench Sensor(s). Model: 208 Piping Sumprrmnch Sensor(s). Model: X Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: Tank Overfll/High-Level Sensor. Model: Other (specify equipment type and model in Section E on page 2). Otherequipment ment (specify q p type and model in Section E on page 2). Dispenser : 1/2 Dispenser ID: 3/4 X❑ Dispenser Containment Sensor(s) Model: 206 —X-1 Dispenser Containment Sensor(s) Model: 208 X❑ Shear Valve(s). X Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s). 7 Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 x❑ Dispenser Containment Sensor(s) Model:208 X Dispenser Containment Sensor(s). Mcde1:208 X] Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). 7 Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 X❑ Dispenser Containment Sensor(s) Model: 206 ZI Dispenser Containment Sensor(s). Model:208 7X Shear Valve(s). X Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). �, U IV Va IIIry WI grans Iiure marts or uispensers, copy mis 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 manufacturers' guidelines. 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 � Alarm history report Technician Name (print): HEATH MCEVER Certification No.: A27562 Signature: _ License. No.: Testing Company Name:Tanknology Phone No.: (800) 8004633 Site Address: 8501 N. MoPac Expressway, suite 400, Austin, TX 78759 Date of TestinglServicing: 01/17/2007 Monitoring System Certification Page 1 of 3 Based on CA forth dated 03/01