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_ RECEIVED Appendix VI CCT 24 2013 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http..//v�L *WIYI'FllJr VME V I AL MONITORING SYSTEM CERTIFICATION CHEALTH DEPARTMENT For Use By All Jurisdictions Within the State of Califomia 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 cerGfcation or report must be prepared for each monitoring system control panel by the technician who performs the work.A copy of this forth 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 FacilityName: 7-ELEVEN#17334 MKT 2368(N-747) Bldg. No.: Site Address: 4501 N. PERSHING AVE.@ ROSEMARIE LN. City: STOCKTON Zip: 95207 Facility Contact Person: MGR-SATBIR Contact Phone No.: 209-951-6745 Make/Model of Monitoring System: Veeder Root TLS-35OR Date of Testing/Servicing: 10/11/2013 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment Ins ected serviced: Tank ID: T-1-RUL Tank ID: T-2-PUL W/ In-Tank Gauging Probe. Model: mag r In-Tank Gauging Probe. Model: mag W Annular Space or Vault Sensor. Model: 420 r Annular Space or Vault Sensor. Model: 420 W Piping Sump/Trench Sensor(s). Model: 208 r Piping Sump/Trench Sensor(s). Model: 352 r Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Wo Mechanical Line Leak Detector. Model: Red Jacket FXSV r Mechanical Line Leak Detector. Model: Vapodess LD-2000 r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: W 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 Pae 2). r Other(specify a ui men[type 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(s odel:Others eci equipment a and model 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: 352 r Dispenser Containment Sensor(s).Model: 352 r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Floats and Chain($). r Dispenser Containment Floats and Chain(s). Dispenser Dispenser ID: ID: (� Dispenser Containment Sensor(s).Model: r Dispenser Containment Sensor(s).Model: r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)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(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 forn.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 applyr r System set- up r Alarm history report Technician Name(print): Jarrod Cooke Signature: Certification No.: 835255 License.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)800-0633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 10/11/2013 Monitoring System Certification Pape 1 of 3 12/07