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MONITORING SYSTEM CERTIFICATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION / TEST DATE: March 5, 2012 Al. FACILITY A2. OWNER Name 7 -Eleven Market #2368 / Store #19976 Name 7 -Eleven, Inc Address 1399 N. Main Street, Manteca, CA 95336 Address P.O. Box 711, Dallas, TX 75221 Phone# 209-239-3252 Phone# 805-523-2949 Contact Stephen Boyd I I Contact Stephen Boyd A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 600 E. Main Street, Stockton, CA 95202 Address P.O. Box 1025, W. Sacramento, CA 95691 Notified February 29, 2012 Lic # 617238 A, B, Haz Inspector Muniappa Naidu Contact Dulcinea Covan Phone# 209-468-8257 Phone# 916-373-1166 B. I NVE NTO RY 0 F EQU I PME NT TESTED/C ERTI FI ED (Check the appropriate boxes to indicate equipment inspected/serviced) 131: TANKS Tank #1 (Product): Gasoline - 87 Tank #2 (Product): Gasoline -91 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: Annular Space or Vault Sensor Model: 0794380-303 Annular Space or Vault Sensor Model: 0794380-303 Piping Sump / Trench Sensor(s) Model: 0794380-208 Piping Sump / Trench Sensor(s) Model: 0794380-208 Fill Sump Sensor(s) Model: 0794380-208 Fill Sump Sensor(s) Model: 0794380-208 ❑ 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 in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): Tank #4 (Product): _ ❑ 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 in Section E) Model: ❑ Other (specify equipment in Section E) Model: 132: DISPENSERS/UDC's Dispenser # : 1-2 Dispenser # : 3-4 Dispenser Containment Sensor(s) Model: 0794380-208 0 Dispenser Containment Sensor(s) Model: 0794380-208 Shear Valves 0 Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) 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 th 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 ■ System set-up ■ Alarm History Report 1 (�Q �JIJpL �. Wa:-�--�- W -TON— --------_.._. _.— Signature: o ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: March S, 2012 [uiz wanon Engineering, Inc.