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MONITq&ING SYSTEM CERTIF f ATION MAKE I MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION / TEST DATE: Septemeber 2, 2011 Ai. FACILITY A2. OWNER Name 7-Eleven Market#2368 1 Store#14117 Name 7-Eleven, Inc Address 2725 Country Club Lane,Stockton,CA 95201 Address P.Q.Sox 711,Dallas,TX 75221 Phone# 209-463-1259 Phone# 805-523-2949 Contact Stephen Boyd Contact Stephen Boyd A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 600 E. Main street,Stockton,CA 95202 Address P.Q. box 1025,W.Sacramento,CA 95691 Notified August 24,2011 Lic# 617236 A,B,Haz Inspector Stacy Rivera Contact Dulcinea Covan Phone# 916-373-1166 Phone# 209-458-8257 B. INVENTORY OF EQUIPMENT TESTEDICERTIFIED (Check the appropriate boxes to indicate equipment inspectedlserviced) B1: TANKS — Tank#1 (Product}: Gasoline-91 Tank#2 (Product): Gasoline-87 F1 In-Tank Gauging Probe Model: _ _ ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390420 ■ Annular Space or Vault Sensor Model: 0794390 420 ■ Piping Sump 1 Trench Sensor(s) Model: 0794380-208 ■ Piping Sump I Trench Sensor(s) Model: 0794380-208 Fill Sump Sensor(s) Model: ❑ 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 1 High-Level Sensor Model- ❑ Other (specify equipment in Section EJ Model: ❑ Other (specify equipment in Section E) Model: Tank#3 (Product): Tank#4 (Product}: ❑ In Tank Gauging be Model: ❑ In-Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: _ 1 ❑ Annular Space or Vault Sensor Model: Piping Sump I Trench Sensor(s) Model: _ ❑ Piping Sump I Trench Sensor(s) Model: Model: Ll Fill Sump Sensor(s) Model: ❑ Fill Sump Sensors) -- ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: LI Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill 1 High-Level Sensor Model: ❑ Tank Overfill C High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: 132: DISPENSERSIUDC's _. Dispenser#: 1-2 LEIDispenser ser# • Dispenser Containment Sensor(s) Model: 0794380.208 Containment Sensor(s) Model: (♦ Shear Valves ar Valves ❑ Dispenser Containment Floats)and Chains) penser Containment Float(s)and Chain(s) Dispenser#: Dispenser#: ❑ Dispenser Containment Sensors) Model: ❑ Dispenser Containment Sensors) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Floats)and Chain{s) ❑ Dispenser Containment Floats)and Chain(5) Dispenser#: Dispenser# ❑ Dispenser Containment Sensor(s) Model: -1 ❑ Dispenser Containment Sensors) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Floats)and Chains) 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 verity 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 whLTQN. -- Signature: Way ENGINEERING,INC. Date: September 1, 1011 Technician 1 Cert M Jessie Wadkins 1835391 5307888-UT FD 2011 walton Engineering,Inc.