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MONITNG SYSTEM CERTIFITION se By All Jurisdictions Within the State of Califo Authority Cited:Chapter 6.7,N fh and Safety Code;Chapter 16,Division 3 Tifle 23, ifomia 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 owner/operator. The owner/operator must submit a copy of this forth to the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: 7-ELEVEN#32190 City: STOCKTON CA Zip:95206 Site Address: 4943 S.KINGSLEY Contact Phone No: 939-0679 MKT 2237 Date of Testing/Service: 01/23/2006 Facility Contact Person: MGR-LORENA Make/Model of Monitoring System:TLS350 Work Order Number: 2240522 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced TanklD: 1 TanklD: 2 X In-Tank Gauging Probe. Model: MAG ZI In-Tank Gauging Probe. Model: MAG -Xi Annular Space or Vault Sensor. Model: 302 Annular Space or Vault Sensor. Model: 302 71 Piping Sumprrranch Sensor(s). Model: 208 Piping Sumprrranch Sensor(s). Model: 208 X Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: 001 :X1 Electronic Line Leak Detector. Model: 001 Tank Overrill/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 I[3 Tank lD: xj In-Tank Gauging Probe. Model: MAG In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 302 Annular Space or Vault Sensor. Model: X Piping SumprTrench Sensor(s). Model: 208 Piping Sumprrrench 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: 001 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 Section E on page 2). Ispenser 1/2 Dispenser ID: 3/4 X❑Dispenser Containment Sensor(s) Model:208 X Dispenser Containment Sensor(s) Model: 208 XJ Shear Valve(s). �Xj Shear Valve(s) Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 X Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s). Model:208 X❑Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). DispenserlD: 9/10 DispenserlD: 11/12 Dispenser Containment Sensor(s) Model:208X Dispenser Containment Sensor(s). Model:208 QJ( Shear Valve(s). X Shear Valve(s). :1 Dispenser 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 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): E System set-up X❑Alarm history report Technician Name(print): RHOME DESBIENS Signature: Certification No.: 1938 License.No.: Testing Company Name:Tanknology Phone No.: (800)800.4633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 01/23/2006 Page 1 of 3 Based on CA form dated 03/01 Monitoring System Certification