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W T.' n ONITORING SYSTEM CERTIFICATION se By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,139,11th and Safety Code;Chapter 16,Division 3 Title 23,C ornia Code of Regulations This Conn 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: 11/29/2001 Facility Contact Person: MGR-THERESA Make/Model of Monitoring System: VEEDER ROOT Work Order Number: 2219653 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: REG UNL Tank ID: MID UNL 71 In-Tank Gauging Probe. Model: TLS X In-Tank Gauging Probe. Model: TLS X Annular Space or Vault Sensor. Model: TLS Annular Space or Vault Sensor. Model: TLS 71 Piping Sump/Trench Sensor(s). Model: TLS Piping Sump/Trench Sensor(s). Modal. TLS 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.. PLLD X Electronic Line Leak Detector. Model- PLLD Tank Overfill/High-Level Sensor. Model: Tank OverfilVHigh-Level Sensor. Model: Other(specify equipment type and model In Section Eon page 2). Other(specify equipment type and model In Section E on page 2). Tank lD: Tank ID: X In-Tank Gauging Probe. Model: TLS In-Tank Gauging Probe. Model: X Annular Space or Vault Sensor. Model: TLS Annular Space or Vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: TLS Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: FIII 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 Overfill/High-Level Sensor. Model: Tank Ovenl]VHlgh-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). DispenserIU: 1.2 Dispenser ID: 3-4 X Dispenser Containment Sensor(s) Model:TLS X Dispenser Containment Sensor(s) Model:TLS Shear Valve(s). ShearValve(s) ❑Dispenser Containment Float(s)and Chaln(s). 7Dispenser Containment Float(s)and Chaln(s). DispenserlD: 5-6 Dispenser ID: 7-8 X❑ Dispenser Containment Sensors) Model:TLS Dispenser Containment Sensor(s). Model:TLS Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chaln(s). Dispenser ID: 9-10 Dispenser ID: 11-12 ro1lDispenser Containment Sensor(s) Model:TLS X Dispenser ContalnmentSensor(s). Model:TLSShear Velvets). ShearValve(s). Dispenser Containment Float(s)and Chaln(s). F7 Dispenser Containment Float(s)and Chaln(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 report, ❑X Alarm history report X� PRINTED NAME.ANEIL CHAND SIGNATURE: .r� ✓ . COMPANY: Tanknoloay PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 03/01