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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hfp://Www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATIONENVIRCNI�/i -� , I ';L HEALTH For Use By All Jurisdictions Within the State of California r� 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 #19976, MKT 2368 Bldg. No.: Site Address: 1399 N. MAIN ST.@ NORTHGATE Facility Contact Person: BEN Contact Phone No.: 209-239-3252 Make/Model of Monitoring System: Veeder Root TLS -350 PLUS B. Inventory of Equipment Tested/Certified Check the anornnriate hnYec to indicate cnecific Pnuinment incnPrtPd/cervired! City: MANTECA Zip: 95336 Date of Testing/Servicing: 9/19/2017 Tank ID: T4:UNLEADED - RUL Tank ID: TS:PREMIUM - PUL In -Tank Gauging Probe. Model: MAG rV_ In -Tank Gauging Probe. Model: MAG r Annular Space or Vault Sensor. Model: 794380-302 rV_ Annular Space or Vault Sensor. Model: 794380-302 P Piping Sump / Trench Sensor(s). Model: 794380-208 W Piping Sump / Trench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 rV_ Fill Sump Sensor(s). Model: 794380-208 W Mechanical Line Leak Detector. Model: Vaporless LD -2000 rV_ Mechanical Line Leak Detector. Model: Vaporless LD -2000 r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: FLAPPERS r%0 Tank Overfill / High -Level Sensor. Model: FLAPPERS Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2).— .Tank Tank ID: Tank ID: r In -Tank Gauging Probe. Model: F In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: (— Mechanical Line Leak Detector. Model: F Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: (i/ Dispenser Containment Sensor(s). Model: 794380-208 jV Dispenser Containment Sensor(s). Model: 794380-208 r Shear Valve(s). Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). (— Dispenser Containment Float(s) and Chain(s). Tir me racnity contains more ranKs or aispensers, copy tnis corm. inauae inrormation for every tank ana dispenser at tree tacuity. 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): r System set- up P Alarm history report Technician Name (print): ]esus Saldivar Certification No.: 845334 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Signature: License. No.: 743160 Class'A' Phone No.: (800) 800-4633 Page 1 of 3 Date of Testing/Servicing: 9/19/2017 12/07