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JUL-03-2002 14:29 SOUTHLAND CORP NW DIV. 503 977 7711 P. 10i19 IFTgV2M M( )RING SYSTEM ULK l II-K:A l IUN For Use All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Hasith and Safety Code;ChaUter 16,Division 3 Title 23, Callfomia ..is o1 Regulations This form must be used to document testing and servicing or monitoring equipment, if more then one monitoring system control penal Is Installed at the facility,a separate .�artjillzaflon or relaort must be preparedil 1 e by the technician who perform&the work. A copy of Inls form must be provided to the lank systont ownerloperator. The ownerioperator must submit a copy of thle form to the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: 7-ELEVEN #19976 MKT 2237 Cily: MANTECA CA Zip:95338 Site Address: 1399 N.MAIN ST. Contact Phone No:239-3252 a NORTHGATE Date of Testing/Service: 06111/2002 Facility Contact Person: MANAGER Make/Model of Monitoring System: VEEDER ROOT TLS Work Order Number: 2222531 13,Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Inspected/serviced Tank 10: RUL Tank ID; MUL X In-Tank Gauging Prone. Modol: 847390 X In-Tank Gaupino Probe. Model: 647390 7X Annular Space or Vault Sensor. Model; 794390-4*20 Annular Spaco or Vault Sensor. Model; 794390-420 X Piping Sump/Tronch Sensor(s). Model: 794380-208 Piping Sumprrrench Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: FIII Sump Seneor(s), Model: Mechanical Line Leak Detector. Model: FX1 V Mechanical Line Leak Detector. Model: L02000 Electronic Lino Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model; Tank Overfill/High-Level Sensor. Model; Other(&poetry equipment type and model in Section E on page 2). Other(specify equipment type and model In Section E on page 2). Tank/ ankin: X In-Tank Gauging ProDe. Model: 847390 In-Tank Gauging Probo. Model: X Annular Spaco or vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Modal: X Piping SumprT'renctl Sonsor(s). Model: 794360-208 Piping Sump/Trench Sensor(s). Model; FW Sump Sensor(s). Model: FIII Sump Sensor(&), Model: X Mechanical Line Look Delector, Model: FE PETRO LLD Mechanical Line Leak Detector. Model: Eieouonlc Lino Leak Detector. Model: Eleclronle Line Leak Detector. Model: Tonk Overfill/High-Level Sensor. Model: Tank Overfillifllgh-Level Sensor. Model; Olhor(specify equipment type and model In section E on page 2). ONor(specify equipment type and modal in Section E on page 2). Dispenser Dispe — Dlspenser Containment Sonsor(e) Model;794380-208 X DlsDenser Containment Sensors) Model:794380-208 Shear Volvo(:) Shear Valve(s) Dispenser Containment Float(s)and Chaln(s). 7Diepencor Containment Floats)and Chain(&), Dispenser ID, Dispenser 10: Dispenser Containment Sensor(s) Model: Dlspomcr Containment Sensor(a). Model; Shear Valve(s). wear Valve(s), Dispenser Containment Floel(s)and Chain(e). 7Dispenser Containment Float(s)and Chain(s). Dispenser ID; Dispenser ID: 710isponsor Containment Sensors) Model: Dispenser Containment Sonsor(s). Model: Shear Valve(&), Shear Velve(s), Dispenser Containment Float(s)and Chain(a). Dlspeneer Containment Floats)and Chaln(s). -If the facility contains more tanks or dispensers,copy this form.include Information for every tank and dispenser at the faclllry. C. Certification I certify that the equipment Identified in this document was inspected/servicod in accordance with the rnanufamurers'guidelines. Attached to this certification is information(o.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 gensratln9 such roports,I have also attached a copy or the(Check all that apply): System set-up report; Alarm history report QX PRINTED NAME:ANEIL CHAND SIGNATURE: COMPANY; Tanknoloav PHONE NO: (8001800-4633 page 1 of 3 eased on CA form dated 03101