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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://wvvw.swrcb.ca.gov.) - I Hr ALTH 7^ MONITORING SYSTEM CERTIFICATION ENvIRONMEN TG For Use By All Jurisdictions Within the State of California uEPARTMEN Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 13, California ode 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 forth to the local agency regulating UST systems within 30 days of test date. A. General Information FacilityName: 7 -ELEVEN #17647, MKT 2368 (N-744) Bldg. No.: Site Address: 1048 W. YOSEMITE AVE@ EL PORTEL Facility Contact Person: DEALER-ANTWAN Make/Model of Monitoring System: Veeder Root TLS -350 Date of Testing/Servicing: 7/13/2017 B. Inventory of Equipment Tested/Certified City: MANTECA Contact Phone No.: 209-239-2329 Zip: 95336 Check the appropriate boxes to indicate specific equipment inspectealservices: Tank ID: T-1 - RUL Tank ID: T-2 - PUL In -Tank Gauging Probe. Model: MAG r7o In -Tank Gauging Probe. Model: MAG r Annular Space or Vault Sensor. Model: 794390409 WO Annular Space or Vault Sensor. Model: 794390409 Piping Sump / Trench Sensor(s). Model: 794380-208 r%_0 Piping Sump / Trench Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: Veeder Root FX1V r Mechanical Line Leak Detector. Model: Veeder Root FX1V r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: FLAPPERS rv—O Tank Overfill / High -Level Sensor. Model: FLAPPERS Other(specify equipment a and model in Section E on Pae 2 . Other (specify equipment a and model in Section E on Pae 2). Tank ID: Tank ID: r In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: r Annular Space or Vault Sensor. Model: r Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: Other (specify equipment a and motlel in Section E on Pae 2 . Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: r%' Dispenser Containment Sensor(s). Model: 794381-208 r Dispenser Containment Sensor(s). Model: 794380-208 r% Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Floats and Chain(s). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve($). Dispenser Containment Floats and Chain(s). Dispenser Containment Float(s) and Chains . Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). r Shear Valve(s), Dispenser Containment Float(s) and Chain(s). 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 tacnity. 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 appW r System set- up r Alarm history report Technician Name (print): )esus Saldivar Certification No.: B45334 Signature: License. No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800) 8004633 Testing Company Address: 11000 N. MoPac Expressway Suite Soo Monitoring System Certification Page 1 of 3 Date of Testing/Servicing: 7/13/2017 12/07