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MONIT �TIFIG SYSTEM CERION e All Jurisdictions Within the State of California Authority Cited. Chapter 6.7, Hea th and Safety Code; Chapter 16, Division 3 Title 23, Ca i ornia 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 #32262, MKT 2368 (N-3940-1 Site Address: 2360 W GRANTLINE 1-205 OFF RAMP Facility Contact Person: CHANDRA Make/Model of Monitoring System:TLS-350 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced City: TRACY CA Zip: 95376 Contact Phone No: 830-9917 Date of Testing/Service: 04/08/2011 Work Order Number: 2280496 Tank ID: T-4 RUL Tank ID: T-5 MUL In -Tank Gauging Probe. Model: MAG FX1 In -Tank Gauging Probe. Model: MAG X Annular Space or Vault Sensor. Model: 302 Annular Space or Vault Sensor. Model: 302 )( Piping Sump/Trench Sensor(s). Model: 352 1-71 Piping Sump/Trench Sensogs). Model: 352 �( Fill Sump Sensogs). Model: 208 Fill Sump Sensor(s). Model: 208 X Mechanical Line Leak Detector. Model: LD2000%� Mechanical Line Leak Detector. Model: FEPETRO MLD Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Tank Overfill/High-Level Sensor. Model: FLAPPER Tank Overfill/High-Level Sensor. Model: FLAPPER Other (specify equipment type and model in Section E on page 2). ❑ Other (specify equipment type and model in Section E on page 2). Tank U - TanklD: In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 302 Annular Space or Vault Sensor. Model: --1 Piping Sump/Trench Sensogs). Model: 352 Piping Sump/Trench Sensogs). Model: X Fill Sump Sensogs). Model: 208 Fill Sump Sensogs). Model: X Mechanical Line Leak Detector. Model: LD2000 7Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: FLAPPER 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). Dispenser : 1/2 Dispenser ID: 3/4 ® Dispenser Containment Sensors) Model: 352 FX -1 Dispenser Containment Sensors) Model: 352 X❑ Shear Valve(s). X Shear Valve(s) ❑ Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 X❑ Dispenser Containment Sensors) Model: 352 X Dispenser Containment Sensors). Model: 352 X❑ Shear Valve(s). 71 Shear Valve(s). 11 Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: 11/12 RI Dispenser Containment Sensors) Model: 352 X Dispenser Containment Sensors). Model: 352 ❑X Shear Valve(s).X Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Floats) and Chain(s). " If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. 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): ❑X System set-up X❑ Alarm history report Technician Name (print): JON ADAMS Signature: �^ Certification No.: B37367 License. No.: 743160 (Class 'A' General Enginering Contractor License) Testing Company Name:Tanknology Phone No.: (800) 800-4633 Site Address: 11000 N. MoPac Expressway, suite 500, Austin, TX 78759 Date of Testing/Servicing: 04/08/2011 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08