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MONITNG SYSTEM CERTIFITION se By All Jurisdictions Within the State of Califon Authority Cited:Chapter 6.7,He th and Safety Code;Chapter 16,Division 3 Title 23, ifomia 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#32190,MARKET#2237 City: STOCKTON CA Zip:95206 Site Address: 4943 S.KINGSLEY(FRONTAGE RD) Contact Phone No: 939-0679 HWY 99 @ ARCH AIRPORT RD Date of Testing/Service: 05/12/2005 Facility Contact Person: MGR-LORENA Make/Model of Monitoring System:VEEDER ROOT TLS Work Order Number: 2235791 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: SUPER Tank ID: MIDGRADE X In-Tank Gauging Probe. Model: 847390-107 X In-Tank Gauging Probe. Model: 847390-107 X Annular Space or Vault Sensor. Model: 794380-302 Annular Space or Vault Sensor, Model: 794380-302 )( Piping Sumprrrench Sensor(s). Model: 794380-208 794380-208 X Fill Sump Sensor(s). Model: 794380-208 Piping Sum prriench Sensor(s). Model: Mechanical Line Leak Detector. Model: Fill Sump Sensor(s). Model: 794380-208 71 PLLD Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD Tank Overfill/High-Level Sensor. Model: Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Others ( pacify equipment type and model in Section E on page 2). Tank ID: RFGIJLAF< Tank ID: X1 In-Tank Gauging Probe. Model: 847390-107 In-Tank Gauging Probe. Model:— X1 odel:X Annular Space or Vault Sensor. Model: 794380-302 Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 794380-208 Piping Sump/Trench Sensor(s). Model: X Fill Sump Sencor(s). Model: 794380-208 Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD Electronic Line Leak Detector. Model: Tank OverfilliHigh-Level Sensor. Model: Tank OverfilliHigh-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other(specify equipment page 2), ( p fytype and model in Section E on Ispenser : 1-2 Dispenser ID: 3:4- 3q Dispenser Containment Sensor(s) Model:794380-2089 X Dispenser Containment Sensor(s) Model: 794380-208 OShear Valve(s). X Shear Valves) Dispenser Containment Float(s)and Chain(s). Dispenser Cpntainment Float(s)and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 X❑ Dispenser Containment Sensor(s) Model:79430-208 Dispenser Containment Sensor(s). Model:79430-208 X❑ Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9-10 Dispenser ID: 11-12 X Dispenser Containment Sensor(s) Model:794380-208 X Dispenser Containment Sensor(s). Model:794380-208 RX Shear Valve(s). -Xj Shear Valve(s). ❑ 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): ❑System set-up Alarm history report Technician Name(print): ANEIL CHAND Signature: AUA" Certification No.: License.No.: Testing Company Name:Tanknology Phone No.: (800)800-4633 Site Address: 8501 N. MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 05/12/2005 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01