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MONIT(' 'RING SYSTEM CERTV CATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION / TEST DATE: Au ust 12, 2013 Al. FACILITY A2. OWNER Name 7-Eleven Market#2368/Store#17334 Name 7-Eleven, Inc Address 4501 North Pershing Street,Stockton,CA 95207 Address P.O. Box 711, Dallas,TX 75221 Phone# 209-951-6745 Phone# 805-523-2949 Contact Stephen Boyd 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 7, 2013 Lic# 617238 A, B,Haz Inspector Garrett Backus Contact Dulcinea Coven Phone# 209368-8257 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) 131: TANKS k#1 (Product): Gasoline -87 Tank#2 (Product): Gasollne-91 ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794190.420 ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Piping Sump/Trench Sensorls) Model: 0794390-352 ■ Piping Sump/Trench Sensogs) Model: 0794/90409 ❑ Fill Sump Sensorls) Model: ❑ Fill Sump Sensoria) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model' _ _ 2vil nic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor Model: _ /High-Level Sensor Motlel: ❑ Other (specify equipment in Section E) Model: specify equipment In Section E) Model: Tank#3 (Product): Tank 04 (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/Trench Sensorls) Motlel: _____ ❑ Piping Sump/Trench Sensoria) Model: El Fill Sump Sensoria) Model: ❑ FIII Sump Sensoria) Model: ❑ Mechanical Line Leak Detector Model: _ ❑ Mechanical Line Leak Detector Model; ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model, ❑ Other (specify equipment in Section E) Model: L❑ Other (specify equipment In Section E) Model: Bz: DISPENSERS/UDC's Dispenser#: 1-2 _ _ Dispenser#: 3-4 ■ Dispenser Containment SemModel: 0784380462 ■ Dispenser Containment Sensor(s) Model: 0784390462 ■ Shear Valves '' ■ Shear Valves [I Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) Dispenser# Dispenser# ❑ Dispenser Containment Sensorls) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valvas ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float's)and Chaln(s) Dispenser#: LDispenser# ❑ Dispenser Containment Sensorls) Model: ❑ Dispenser Containment Sensorls) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float's)and Chaln(s) ❑ Dispenser Containment Float(s)and Chalnhi 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 ■ Alarm History Report te.� - Ir-)ak-b', WALTON Signature: 1 ENGINEERING,INC. Technician/Cert#: Jessie Wadkins/B35391 5307886-UT Date: August 12, 2013 0 2013 Walton Engineering,Inc,