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MONITC*ING SYSTEM CERTIIWATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: July 1. 2010 A1. FACILITY Name 7 -Eleven Market #2368 / Store #32262 Address 2360 West Grantline Road, Tracy, CA 95376 Phone # 209-830-9917 Contact Ian Moorhead A2. OWNER Name 7 -Eleven, Inc Address P.O. Box 711, Dallas, TX 75221 Phone # 805-523-2949 Contact Ian Moorhead A3. C U P A INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health B1: TANKS Name Walton Engineering, Inc. Address 600 E. Main Street, Stockton, CA 95202 Address P.O. Box 1025, W. Sacramento, CA 95691 Notified June 24, 2010 Lic # 617238 A, B, Haz Inspector Stacy Rivera Tank #1 (Product): Gasoline - 87 Contact Richard Walton Phone # 209-468-8257 In -Tank Gauging Probe Phone # 916-825-3203 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS Tank #1 (Product): Gasoline - 87 Tank #2 (Product): Gasoline - 89 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794380-340 ■ Annular Space or Vault Sensor Model: 0794380-340 ■ Piping Sump / Trench Sensor(s) Model: 0794380-352 ■ Piping Sump / Trench Sensor(s) Model: 0794380-352 ■ Fill Sump Sensor(s) Model: 0794380-352 ■ Fill Sump Sensor(s) Model: 0794380-352 ❑ 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 / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): Gasoline - 91 Tank #4 (Product): ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794380-340 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) Model: 0794380-352 ❑ Piping Sump I Trench Sensor(s) Model: ■ Fill Sump Sensor(s) Model: 0794380-352 ❑ 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 I High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: 132: DISPENSE RS/UDC's Dispenser # : 1-2 Dispenser # : 3-4 ■ Dispenser Containment Sensor(s) Model: 0794380-352 ■ Dispenser Containment Sensor(s) Model: 0794380-352 ■ 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: 0794380-352 ■ Dispenser Containment Sensor(s) Model: 0794380-352 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : 9-10 Dispenser # : 11-12 , ■ Dispenser Containment Sensor(s) Model: 0794380-352 ■ Dispenser Containment Sensor(s) Model: 0794380-352 ■ 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 Signature: 0 � WALTON ' ` — _.. ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B36391 5307886 -UT Date: .July 1, 2010