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MONITC -IING SYSTEM CERTIF;.ATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION / TEST DATE: Jul 26, 2012 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 July 23, 2012 Lic# 617238 A,B, Haz Inspector Garret Backus Contact Dulcinea Covan Phone# 209-468-8257 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) Bt: TANKS Tank#1 (Product): Tank#2 (Product): Gasoline-91 ❑ 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 Sensors) Model: 0 Piping Sump/Trench Sensoria) Model: 0794380-208 ❑ FIII Sump Sensoria) Model: ❑ Fill Sump Sensors) 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: ❑ 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/Trench Sensors) Model: ❑ Piping Sump/Trench Sensoria) Model: ❑ Fill Sump Sensors) 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: ❑ Omer (specify equipment In Section E) Model: ❑ Other (specify equipment In Section E) Model: B2: DISPENSERS/UDC's Dispenser#: Dispenser# ❑ Dispenser Containment Sensors) Model: ❑ D�Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Floats)and Chain(s) ❑ Dispenser Containment Float(s)and Chaln(s) Dispenser#: Dispenser# ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensoria) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chaln(s) Dispenser#: Dispenser# ❑ Dispenser Containment Sensoria) Model: ❑ Dispenser Containment Sensoria) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Floats)and Chains) ❑ Dispenser Containment Float(s)and-Chain(s) 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 Signature: Technician/Cent#: Curtis Carpenter 1837258 8020679 Date: July 26 2012 ©2012 Walton Engineering,Inc.