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• i «ECEIVEE Appendix VI y p 2015 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://v vw.swrcb.ca. MONITORING SYSTEM CERTIFICATION LNVIRdNMENTAI For Use ay All-lurisdictlons Within the State of California 17�'n +_ nr-D2grn nr•gr� Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,Title 23,California CoBe of Regulations This forth must be used to document testing and servicing of monitoring equipment.A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work.A ropy of this form must be provided to the tank 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. A.General Information Facility Name: ]-ELEVEN#32190,MKT 2368 Bldg.No.: Site Address: 4943 S.IONGSLEY(FRONTAGE RD)HWY 99 @ ARCH AIRPORT RD City: STOCKTON Zip: 95206 Facility Contact Person: MGR-LORENA Contact Phone No.: 209-939-0679 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 5/12015 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment ins ctetl serviced: Tank ID: T4-RUL Tank ID: TS-MUL r, in-Tank Gauging Probe. Model: 846390-107 r In-Tank Gauging Probe. Model: 846390-107 r Annular Space or Vault Sensor. Model: 794380-302 r Annular Space or Vault Sensor. Model: 794380-302 R Piping Sump/Trench Sensor(s). Model: 7943BO-208 [ Piping Sump/Trench Sensor(s). Model: 794380-208 P01 Fill Sump Sensor(s). Model: 794380-208 Rd Fill Sump Sensor(s). Model: 794380-208 r Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: rElectronic Line Leak Detector. Model: Veeder Root PLLD J Electronic Une Leak Detector. Model: Veeder Root PLLD r Tank Overfill/High-Level Sensor.Model: Flapper Valve J Tank Overfill/High-Level Sensor.Model: Flapper Valve Other(specifyequipment a and model in Section E on Pae 2. Others eci equipment a and model in Section E on Pae 2). Tank ID: T6-PUL Tank ID: rj In-Tank Gauging Probe. Model: 846390-107 r In-Tank Gauging Probe. Model: r Annular space or Vault Sensor. Model: 794380-302 r Annular Space or Vault Sensor. Model: r Piping Sump/Trench Sensor(s). Model: 794380-208 r Piping Sump/Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: 7943W208 r Fill Sump Sensor(s). Model: rl Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic Line Leak Detector. Model: r Tank Overfill/High-Level Sensor.Model: Flapper Valve r Tank Overfill/High-Level Sensor.Model: I Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment and model in Section E on Pae 2). Dispenser �2 Dispenser 7/8 ID: ID: r Dispenser Containment Sensor(s).Model: 794-AW208 VI Dispenser Containment Senscr(s).Model: 79438D20B r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Floats and Chaln s. Dispenser 3/4 Dispenser 9/10 ID: ID: r Dispenser Containment Sensor(s).Model: 794380-208 r Dispenser Containment Sensor(s).Model: 794380-208 r Shear Valve(s), NI,Shear Valve(s). Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chaln(s). Dispenser 5/6 Dispenser 11/12 ID: ID: r Dispenser Containment Sensor(s).Model: 794380-20B r Dispenser Containment Sensor(s).Model: 794380-208 r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r 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 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 appW..ri System set- up r�Alarm history report Q0 Technician Name(print): Darren Sclume Signature: ` Certification No.: B35390 License.No.: 743160 Class W Testing Company Name: Tanknology Phone No.: (800)800-0633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 5/12015 Monitoring System Certification Page 1 of 3 12/07