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MONI RING SYSTEM CERTIFICATION r Use By All Jurisdictions Within the State of Calik Authority Cited: Chapter 6.7,qRrealth and Safety Code, Chapter 16, Division 3 Title 2-, —alifornia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility, 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 2237 Site Address: 1399 N. MAIN ST. @ NORTHGATE Facility Contact Person: MANAGER Make/Model of Monitoring System: VEEDER-ROOT B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: MANTECA Contact Phone No: 239-3252 Date of Testing/Service: 01/18/2005 Work Order Number: 2234065 CA Zip: 95336 Tank ID: RUL Tank ID: PUL 71 In -Tank Gauging Probe. Model: MAG -1 In -Tank Gauging Probe. Model: MAG -1 Annular Space or Vault Sensor. Model: 794380-302 X❑ Annular Space or Vault Sensor. Model: 794380-302 Piping SumprTrench Sensor(s). Model: 794380-208 X❑ Piping Sumprrrench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: 794380-208 Mechanical Line Leak Detector. Model: FX1V X ❑ Mechanical Line Leak Detector. Model: LD2000 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 type and model in Section E on page 2). ❑ Other (specify equipment type and model in Section E on page 2), an an 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 SumpfTrench 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 type and model in Section E on page 2). ❑ Other (specify equipment type and model in Section E on page 2). ispenser ® Dispenser Containment Sensor(s) Model: 794380-208 Dispenser Containment Sensor(s) Model: 794380-208 ® Shear Valve(s). ® Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). DispenserDispenser ❑ 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 ID: Dispenser ID: ❑ Dispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). F I Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). IT the taclllty contains more tanKs or aispensers, copy ins Torm. Incivae InTormatlon Tor every tank and alSpenser at the taclllty. 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 Site Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the (Check all that apply): ❑ System set-up ® Alarm history report Technician Name (print): HEATH MCEVER Certification No.: 3604 Testing Company Name: Tanknology Site Address: 8900 Shoal Creek, Bldg. 200 Austin, TX 78757 Signature: License. No.: Phone No.: (800) 800-4633 Date of Testing/Servicing: 01/18/2005 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01