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1pTankrK*)gy MONITORING SYSTEM CERTIFICATION se By All Jurisdictions Within the State of Califon Authority Cited:Chapter 6.7, 07 and Safety Code;Chapter 16,Division 3 Title 23, tfomia Code of Regulations This form must be used to document testing and servicing of monitoring equipm certification or report must be Prepant. If more than one monitoring system control panel is installed at the facility,a separate ared 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 Facility Contact Person: MGR-THERESA Date of Testing/Service: 05/14/2002 Make/Model of Monitoring System: VR TLS-350 Work Order Number: 2222221 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: REG Tank ID: PLS X In-Tank Gauging Probe. Model: 847380-109 X In-Tank Gauging Probe. Model: 847380-109 X Annular Space of Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. model: 794390-420 X Piping Sump/Trench Sensor(s). Model: 794380-208 794380-208 Piping Sump/Trench Sensor(s). Model:Fill Sump Sensoria). Model: Mechanical Line Leak Detector. Model: FII Sump Sensor(s). Model: Electronic Line Leak Detector, Model: PLLD Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD 71 Tank OverfilVHigh-Level Sensor. Model: 61S0 X Tank OvertilVHigh-Level Sensor. Model: 6150 Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E o Tank ID: (spe n page 2). Tank lD: X In-Tank Gauging Probe. Model: 847380-109 In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Model, X Piping Sump/Trench Sensor(s). Model: 794380-208 Piping Sump/Trench Sensor(a). Model: Fill Sump Sensor(a). Model: Mechanical Line Leak Detector. Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PLLD Electronic Line Leak Detector. Model, X Tank OverfilVHigh-Level Sensor. Model: 61 S0 Tank Overfill/High-Level Sensor. Model: Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). Ispenser : 1/2 Dispenser ID: 7/8 Q Dispenser Containment Sensor(s) Model:794380-208 :xl Dispenser Containment Sensor(s) Model:794380-208 X❑Shear Valve(s). Shear Vafve(s) Dispenser ContaX inment Float(s)and Cham(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 3/4 Dispenser ID: 9/10 X Dispenser Containment Sensor(s) Model:794380-208 Dispenser Containment Sensoris). Model:794380-208 XX Shear VaNe(a). Shear Velvets).Dispenser Containment Float(s)antl Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5/6 DispenserlD: 11/12 QDispenser Containment Sensor(s) Model:794380-208 Dispenser Containment Sensoria). Model:794380-208 X1 Shear Valve(s). X Shear Velvets). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). C. Certification If the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility. 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 report; Alarm history report PRINTED NAME:MICHAEL T LEVESQUE SIGNATURE: /" 4 COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01