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Appendix VI JUL 2 5 2016 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://WWW.SWrcb.Oe►yq - MONITORING SYSTEM CERTIFICATION "" ' "` �I" For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form 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 copy 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: 7 -ELEVEN #17647, MKT 2368 (N-744) Bldg. No.: Site Address: 1048 W. YOSEMITE AVE@ EL PORTEL City: MANTECA Zip: 95336 Facility Contact Person: DEALER-ANTWAN Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the appropriate loxes to indicate specific emdoment insoected/serviced: Contact Phone No.: 209-239-2329 Date of Testing/Servicing: 7/19/2016 Tank ID: T-1 - RUL Tank ID: T-2 - PUL ❑JJ In -Tank Gauging Probe. Model: mag ❑V In -Tank Gauging Probe. Model: mag ❑Q Annular Space or Vault Sensor. Model: 794380-409 Annular Space or Vault Sensor. Model: 794380-409 Piping Sump / Trench Sensor(s). Model: 794380-208 ❑v Piping Sump / Trench Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: R Mechanical Line Leak Detector. Model: Veeder Root FXSV Mechanical Line Leak Detector. Model: Veeder Root FX1V ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: flapper Tank Overfill / High -Level Sensor. Model: flapper Other (specify equipment type and model in Section E on Pa e 2 . Othersecify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: Other (specify equipment a an r7 Other (specify equipment type and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 n Shear Valve(s). n Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ 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 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 apply): Rl System set- up R' Alarm history report Technician Name (print): Jarrod Cooke Certification No.: 835255 Signature: License. No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 7/19/2016 Monitoring System Certification Page 1 of 3 12/07