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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 ENVRONMENTAL For Use By All Jurisdictions Within the State of California W C �N € - l rh7MR I -,TJ _� 17Kt7 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 -350R B. Inventory of Equipment Tested/Certified rhnnl, fhn a :afn h ---c ♦n inilireln a Af." I—A—A. Date of Testing/Servicing: 3/3/2016 Tank ID: Tank ID: r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: r• Annular Space or Vault Sensor. Model: ; Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: j Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r~ Mechanical Line Leak Detector. Model: J Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: [ i Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pa e 2 . Other(specify equipment a and model in Section E on Page 2). Tank ID: Tank ID: In -Tank Gauging Probe. Model:r In Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: n Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other (seecify equipment a and model in Section E on Pa e 2). r Other (specify equipment t e and model in Section E on Page 2). Dispenser 1/2 Dispenser 3/4 ID: ID: r Dispenser Containment Sensor(s). Model: 784380-352 r Dispenser Containment Sensor(s). Model: 784380-352 Shear Valve(s). P Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: F71 Dispenser Containment Sensor(s). Model: 784380-352 r Dispenser Containment Sensor(s). Model: 784380-352 [Nj Shear Valve(s). r Shear Valve(s). j Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: PF Dispenser Containment Sensor(s). Model: 784380-352 P; Dispenser Containment Sensor(s). Model: 784380-352 Pi Shear Valve(s). r Shear Valve(s). j Dispenser Containment Float(s) and Chain(s). �` Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this Corm. Include information for every tank and dispenser at the tacllity. 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 Alarm history report Technician Name (print): Nicolas Poblano Certification No.: 845361 License. No.: Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Signature: 743160 Class 'A' Phone No.: (800) 800-4633 Monitoring System Certification Page 2 of 4 Date of Testing/Servicing: 3/3/2016 12/07