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MONITING SYSTEM CERTIFICVION se By All Jurisdictions Within the State of California 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. 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 b system ownerlaperator. The owner/operator must submit a copy of this farm to y the technician who performs the work. A copy of this form must be provided to the Tank the focal agency regulating UST systems within 3C days of test date. A.General Information Facility Name: 7-ELEVEN#14117,MKT 2368 City: STOCKTON CA Zip:95204 Site Address: 2725 COUNTRY CLUB BLVD Contact Phone No: 463-1259 Date of Testing/Service: 03/09/2010 Facility Contact Person; MANAGER-GIL Make/Model of Monitoring System:TLS-350 Work Order Number: 2272773 B.Inventory of Equipment'Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: 1 PUL Tank ID: 2 RUL X In-Tank Gauging Probe. Model: MAG 1X1 In-Tank Gauging Probe. 9 9 Model: MAG X Annular Space or Vault Sensor, Model: 42 Annular Space or Vault Sensor. Model: 420 X Piping Sumpffrench Sensor(s). Model: 352 Piping Sump/Trench Sensors). Model: 352 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: X Mechanical Line Leak Detector. Model: FX1V X 99LD2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Q X Tank Overfill/High-Level Sensor. Model: FLAPPER EXT ALARM Electronic Line Leak Detector. Model: Tank OverfilllHigh-Level Sensor. Model; Other(specify equipment type and model in Section E on page 2). ❑ TanklD: Other(specify tyequipment type and model in Section E onpage 2). �TanklD: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: E] Annular Space or Vault Sensor. Model: Piping Sumpfrrench Sonsor(s). Madel: El Piping Sumprr'anch Sensor(s). Model: FIII Sump Sensors). Model: Mechanical Line Leak Detector, Model: Ll Fill Sump Sensor(s). Model: Electronic Line Leak Detector. Model: mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Ove�l1lHigh-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Tank OventilllHigh-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). ispenser : 1!2 Dispenser ID: ®Dispenser Containment Sensor(s) Model:208 Dispenser Containment Sensor(s) ModeP: ®Shear Valve(s). Shear Valve(s) ElDispenser Containment Float(s)and Chain(s). Dispenser Containment Roat(s)and Chain(s). Dispenser ID: Disperser ID: Dispenser Containment Sensor(s) Model; pispenser Containment Sensor(s). Model: Q Shear Valve(s). [ Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: DispenserlD: QDispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valves). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)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): 0 System set-up Alarm history report Technician Name(pant): KRISTOPHER BELL Signature: Certification No.: 833709 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: 03109/2010 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/08