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Q j 0 2 V16 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://wvvw.swrcb.ca.gov.) ENVIRONMENTAL HEALTH MONITORING SYSTEM CERTIFICATION DEPARTMENT For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, 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 #17334 MKT 2368 (N-747) Bldg. No.: Site Address: 4501 N. PERSHING AVE nn ROSEMARIE LN. Facility Contact Person: MGR - SATBIR Make/Model of Monitoring System: Veeder Root TLS -350R B. Inventory City: STOCKTON Contact Phone No.: 209-951-6745 of Equipment Tested/Certified Check the annronriate boxes to indicate specific eauinment inspected/serviced: Zip: 95207 Date of Testing/Servicing: 9/28/2018 Tank ID: T 1 RUL *If the facility contains more tanks or dispensers, copy this form. Include information for every Tank ID: In -Tank Gauging Probe. Model: 846390-109 In -Tank Gauging Probe. Model: W Annular Space or Vault Sensor. Model: 794390-420 (� Annular Space or Vault Sensor. Model: P Piping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: I, Fill Sump Sensor(s), Model: Fill Sump Sensor(s). Model: I✓. Mechanical Line Leak Detector. Model: Red Jacket FX1V Mechanical Line Leak Detector. Model: F. Electronic Line Leak Detector. Model: (° Electronic Line Leak Detector. Model: Iv Tank Overfill / High -Level Sensor, Model: Flapper Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pa e 2). Other(specify equipment a and model in Section E on Pae 2). Tank ID: T-2 - PUL Tank ID: I✓ In -Tank Gauging Probe. Model: 846390-109 In -Tank Gauging Probe. Model: F Annular Space or Vault Sensor. Model: 794390-420 Annular Space or Vault Sensor. Model: FV Piping Sump / Trench Sensor(s). Model: 794380-208 Piping Sump / Trench Sensor(s). Model: F, Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: I✓ Mechanical Line Leak Detector. Model: Vaporless LD -2000 Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: F Tank Overfill / High -Level Sensor. Model: Flapper Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Page 2 . Other(specify equipment a and model in Section E on Pae 2), Dispenser 1/2 Dispenser ID: ID: Dispenser Containment Sensor(s), Model: 794380-352 Dispenser Containment Sensor(s). Model: F Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 3/4 Dispenser ID: ID: Dispenser Containment Sensor(s). Model: 794380-352 Dispenser Containment Sensor(s), Model: I✓: Shear Valve(s). Shear Valve(s). r, Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s), Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). 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 F Alarm history report Technician Name (print): Brent Bowen Certification No.: 642815 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Signature: r'�� License. No.: 743160 Class 'A' Phone No.: (800) 800633 Page 1 of 3 Date of Testing/Servicing: 9/28/2018