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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hfp://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State ofC'alifomia Authority Cited:Chapter 6.7,Health and Safety Code;Chapter 16, Division 3, Title 13, California Code of 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 B.Inventory of Equipment Tested/Certified Date of Testing/Servicing; 5/23/2013 Check tinea ro nate boxes to indicates cific a u ment ins ected serviced. Tank IDs T4-RUL r nk ID: T5-MUL W In-Tank Gauging Probe. Model: Ma In-Tank Gau in Probe. MAnnular Space or Vault Sensor. Model: 302 g g Annular Space or Vault Sensor. Model: 302 W Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s), Model: 208 r Fill Sump Sensor(s). Model: 208 P-0 Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Veeder Root PLLD Electronic Line Leak Detector. Model: Veeder Root PLLD r Tank Overfill/High-Level Sensor,Model: Flapper r Tank Overfill/High-Level Sensor.Model: Flapper Others eci equipment a and model in Section E on Pa e 2 . ` Others eci a ui ment a and model in Section E on Pa e 2). Tank ID: T6-PUL Tank IDs TP In-Tank Gauging Probe. Model:_Mag r In-Tank Gauging Probe. Model: ✓ Annular Space or Vault Sensor. Model: 302 F Annular Space or Vault Sensor. Model: W Piping Sump/Trench Sensor(s). Model: 208 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: 170 Electronic Line Leak Detector. Model: Veeder Root PLLD r Electronic Line Leak Detector. Model; fV_ Tank Overfill/High-Level Sensor.Model:—Flapper r Tank Overfill/High-Level Sensor.Model: Other(specify equip ment type and model in Section E on Pa e 2 . Other Snprifva ui ment a and model m Section E on Pa e 2 . IDspenser 1/2 Dispenser IDs 3/4 r Dispenser Containment Sensor(s).Model: 208 r Dispenser Containment Sensor(s).Model: 208 WO Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). IDspenser 5/6 =� n r Dispenser Containment Sensor(s).Model: 208f:j ainment Sensor(s).Model: 208 P Shear Valve(s). .r Dispenser Containment Float(s)and Chaln(s). ainment Floats)and Chain(s). Dispenser 9/10 Dispenser IDs IDs 11/12 r Dispenser Containment Sensor(s).Model: 208 r Dispenser Containment Sensor(s).Model: 208 Shear Valve(s). r Shear Valve(s). r Dispenser Containment Floats)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 r Sset- up r Alarm history report em Technician Name(print): Jason Castillo Signature: �•- Certification No.: 842639 License.No.: 743160Class'A' Testing Company Name: Tanknology Phone No.: (BW)800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 5/23/2013 Monitoring System Certification Page I of 3 12/07