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MONIT%RING SYSTEM CERTISCATION MAKE / MODEL OF MONITORING SYSTEM: CERTIFICATION / TEST DATE: November 4, 2011 Al. FACILITY A2. OWNER Name 7-Eleven Market#2369/Store#35355 Name 7-Eleven, Inc Address 3202 W.Hammer Lane,Stockton,CA 95209 Address P.O.Box 711, Dallas,TX 75221 Phone# 209-957-2900 Phone# 805-523-2949 Contact Stephen Boyd 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 November 4,2011 Lic# 617238 A, B,Haz Inspector Garrett Backus Contact Dulcinea Covan Phone# 209-468-8257 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (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: 0847390-107 ■ In-Tank Gauging Probe Model: 0847390-107 ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ❑ 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 I High-Level Sensor Model: ❑ Tank Overfill I High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank#3 (Product): Diesel Tank#4 (Product): _ ■ In-Tank Gauging Probe Model: 0847390-107 ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-409 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ❑ 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: ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Shear Valves ■ Dispenser Containment Float(s)and Chain(s) ■ Dispenser Containment Float(s)and Chain(s) Dispenser#: 5/6 Dispenser#: 7/8 ❑ 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 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): ■ System set-up ■ Alarm History Report GWALTON Signature: I/ ` v ENGINEiEnING� INC. �- Technician/Cert M Jim Cossey/#A22353/80281671CC Date: November 4, 2011 ©2011 Walton Engineering,Inc.