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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION 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 #19976, MKT 2368 Bldg. No.: Site Address: 1399 N. MAIN ST.@ NORTHGATE Facility Contact Person: BEN Contact Phone No. Make/Model of Monitoring System: Veeder Root TLS 350 B. Inventory of Equipment Tested/Certified r'horie tho annrnnriato hnme M indirato enariFr onninmont inenortod /car irode 239-3252 City: MANTECA Zip: 95336 Date of Testing/Servicing: 10/29/2012 Tank ID: T4 - REG UNLEAD Tank ID: T5 - PUL In -Tank Gauging Probe. Model: mag r7o In -Tank Gauging Probe. Model: mag W, Annular Space or Vault Sensor. Model: 303 W Annular Space or Vault Sensor. Model: 303 Piping Sump / Trench Sensor(s). Model: 208 W Piping Sump / Trench Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: 208 r-70 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Vaporless LD -2000 rv— Mechanical Line Leak Detector. Model: Vaporless LD -2000 r- Electronic Line Leak Detector. Model: (- Electronic Line Leak Detector. Model: W Tank Overfill / High -Level Sensor. Model: flapper 170 Tank Overfill / High -Level Sensor. Model: flapper Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Page 2). Tank ID: Tank ID: In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: 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). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s). Model: 208 rv-0 Dispenser Containment Sensor(s). Model: 208 Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). I- Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: j- Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: �- 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). r Dispenser Containment Float(s) and Chain(s). -it the racnity contains more tames or aispensers, copy tnis rorm. incivae mTormation Tor every tanK ano aispenser at the Tacwty. 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): P System set- up rvo Alarm history report Technician Name (print): Jarrod Cooke Certification No.: B35255 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: 10/29/2012 12/07