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0 0 REGEIVEL Appendix VI MAR 0 9 2016 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION ENViRONMENTAL For Use By All Jurisdictions Within the State of California 1177—MMT, ,1`79L9 ' Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. 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 Bldg. No.: Site Address: 2360 W GRANTLINEI-205 OFF RAMP City: TRACY Zip: 95376 Facility Contact Person: CHANDRA Contact Phone No.: 209-830-9917 Make/Model of Monitoring System: Veeder Root TLS-35OR B. Inventory of Equipment Tested/Certified /•I.e, ♦Mu .a4u r...vec—;.A; +_c �iFin on ofi nrf nel /curvireil• Date of Testing/Servicing: 3/3/2016 Tank ID: T4 RUL - REG UNLEAD Tank ID: T5 MUL - MIDGRADE In -Tank Gauging Probe. Model: Mag � In -Tank Gauging Probe. Model: Mag r7 Annular Space or Vault Sensor. Model: 794380-303 -3 R. Annular Space or Vault Sensor. Model: 794380-303 L 7._ Piping Sump / Trench Sensor(s). Model: 784380-352 / r Piping Sump / Trench Sensor(s). Model: 784380-352 P Fill Sump Sensor(s). Model: 794380-208 171 Fill Sump Sensor(s). Model: 794380-208 r Mechanical Line Leak Detector. Model: Vaporless LD -2000 r Mechanical Line Leak Detector. Model: Vaporless LD -2000 r Electronic Line Leak Detector. Model: r7 Electronic Line Leak Detector. Model: r", Tank Overfill / High -Level Sensor. Model: r,/—,l Tank Overfill / High -Level Sensor. Model: 1 Other(specify equipment t e and model in Section E on Page 2). Other(specify equipment a and model in Section E on Page 2). Tank ID: T6 PUL - PREMIUM 4411,Tank ID: RF In -Tank Gauging Probe. Model: Mag 4 In -Tank Gauging Probe. Model: Pli Annular Space or Vault Sensor. Model: 794380-303 :3402- Annular Space or Vault Sensor. Model: (�! Piping Sump /Trench Sensor(s). Model: 784380-352 Piping Sump / Trench Sensor(s). Model: [d;' Fill Sump Sensor(s). Model: 794380-208 ri Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Vaporless LD 2000 Mechanical Line Leak Detector. Model: rElectronic Line Leak Detector. Model: j Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model•Tank Overfill /High -Level Sensor. Model: Other(specify equipment a and model in Section E on Page rll Other(specify equipment a and model in Section E on Pace 2). Dispenser 1/ 2 Dispenser 3/4 ID: ID: Rej Dispenser Containment Sensor(s). Model: 784380-352 r Dispenser Containment Sensor(s). Model: 784380-352 — r Shear Valve(s). �' Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r, Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: r Dispenser Containment Sensor(s). Model: 784380-352 ✓ r Dispenser Containment Sensor(s). Model: 784380-352 r Shear Valve(s). r Shear Valve(s). ri Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: r Dispenser Containment Sensor(s). Model: 784380-352 rj Dispenser Containment Sensor(s). Model: 784380-352 r— Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). -it the Taciiity Contains more LanKs or alspensers, copy MIS Corm. 1ncivae Inrorindoon iur every tarlK dnu usptiiser dl Lilt idunry. 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): P System set- up P7, Alarm history report Technician Name (print): Nicolas Poblano Signature: Certification No.: B45361 License. No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: Monitoring System Certification Page 1 of 4 3/3/2016