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00 Appendix VI 00 RECEIVED (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hltp:l/"Afj.�a.gbjy MONITORING SYSTEM CERTIFICATION G di�il! For Use By All Jurisdictions Within the State of California ENVI RONMEN AL Authority Cited: Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, Title 2,� 'Fb�fl�T Regulations This form must be used to document testing and servicing of monitoring equipment.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,MKT 2368 Bldg. No.: Site Address: 4943 S. KINGSLEY(FRONTAGE RD)HWY 99 @ ARCH AIRPORT RD City: STOCKTON Zip: 95206 Facility Contact Person: MGR-LORENA Contact Phone No.: 209-939-0679 Make/Model of Monitoring System: Veeder Root TLS 350 Dae of Testing/Servicing: 5/13/2014 B,Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected serviced: Tank ID: T4-RUL Tank ID: T5-MUL In-Tank Gauging Probe. Model: MAG W In-Tank Gauging Probe. Model: MAG Annular Space or Vault Sensor. Model: 794390-352 r Annular Space or Vault Sensor. Model: 794390-352 17 Piping Sump/Trench Sensor(s). Model: 794380-208 W Piping Sump/Trench Sensor(s). Model: 794380-208 rV_ Fill Sump Sensor(s), Model: 794380-208 ry-1 Fill Sump Sensor(s). Model: 794380-208 r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: rv— Electronic Line Leak Detector. Model: Veeder Root PLLD W Electronic Line Leak Detector. Model: Veeder Root PLLD Tank Overfill/High-Level Sensor.Model: FLAPPER r Tank Overfill/High-Level Sensor.Model: FLAPPER Other(specify equipment a and model in Section E on Rage 2). r Others ecify equipment a and model in Section E on Page 2). Tank ID: T6-RUL Tank ID: r In-Tank Gauging Probe. Model: MAG r In-Tank Gauging Probe. Model: r7 Annular Space or Vault Sensor. Model: 794390-352 r Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 794380-208 r Piping Sump/Trench Sensor(s). Model: W Fill Sump Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic Line Leak Detector. Model: ryo Tank Overfill/High-Level Sensor.Model: FLAPPER r Tank Overfill/High-Level Sensor.Model:. Other(specify equipment a and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Wo Dispenser Containment Sensor(s).Model: 794380-208 r Dispenser Containment Sensor(s).Model: 794380-208 r Shear Valve(s). P7 Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: r7 Dispenser Containment Sensor(s).Model: 794380-208 r Dispenser Containment Sensor(s).Model: 794380-208 r Shear Valve(s). P7 Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser 9/10 Dispenser ID: ID: 11/12 r Dispenser Containment Sensor(s).Model: 794380-208 rvo- Dispenser Containment Sensor(s).Model: 794380-208 P_ Shear Valve(s). (aO Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r 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 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 r Alarm history report Technician Name(print): Gilbert Garcia Signature: Certification No.: 642816 License.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 5/13/2014 Monitoring System Certification page 1 of 3 12/07