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1 ARM Alllllllll� MONI RING SYSTEM CERT ICATION MAKE I MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION/TEST DATE: September 2, 2014 Al. FACILITY A2. OWNER Name7-Eleven Market#2368/Store#32190 Name 7-Eleven, Inc Address 4943 South State Route 99,Stockton,CA 95206 Address R.O.Box 711,Dallas,TX 75221 Phone# 209-939-0679 Phone# 605-523-2949 Contact Stephen Boyd 11 Contact Stephen Boyd A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 1868 E.Hazelton Avenue,Stockton,CA 95202 Address P.O.Box 1025,W.Sacramento,CA 95691 Notified August 28,2014 Lic If 617238 A,B,'Haz Inspector Elena Manzo Contact Dulcinea Cowan Phone# 209-468-8257 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to Indicate equipment Inspected/serviced) Bi: TANKS Tank#1 (Product): _ Tank#2 (Product); Gasoline-89 ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump/Trench Sensor(s) Model: ❑ Piping Sump f Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: p Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: Electronic Line Leak Detector Model: 0841348.0-001 ❑ Tank Overfill!High-Level Sensor Model ❑ Tank Overfill f High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank#3 (Product): Tank#4 (Product): ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump f Trench Sonsor(s) Model: ❑ Piping Sump f Trench Sensor(s) Model: ❑ 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: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill l High-Level Sensor Model: ❑ Tank Overfill 1 High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: 132: DISPENSERSIUDC's Dispenser#: Dispenser# ❑ Dispenser Containment Sensor(s) Model ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s)and Chaln(s) [] Dispenser Containment Float(s)and Chain(s) Dispenser#: Dispenser#: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) Dispenser#: Dispenser# ❑ Dispenser Containment Sensors) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) C. CERTIFICATION I certify that the equipment identified in this document was inspectedlserviced 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 th 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 ■ Alarm History Report tAur WaX� WALTON - -- Signature: ENGINEERING,Itl:,. Technician 1 Cert If: Jessie Wadkins I B35391 5307886-UT Date: September 2, 2014 0 2014 Walton Engineering,Inc.