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RFaxd�( G n Appendix VI OCT 2 6 2015 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:h`wA1yr.sWrob.C3.90V.) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL For Use By All Jurisdictions Within the State ofCalifornla 14FA:Tt.I"701ACMAC1141T Authority Cited.,Chapter 6.7,Health and Safety Code;Chapter 16,Division 3,71tle 13,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 mtechnician copy of this system owner/operator.The form to the local agency regulating UST systems within 30 days of test date owner/operator ust submit a A.General Information FacilityName: 7-ELEVEN#17334 MKT 2368(N-747) Bldg.No.: Site Address: 4501 N.PERSHING AVE.@ ROSEMARIE LN. City: STOCKTON Zip: 95277 Facility Contact Person: MGR-SATBIR Contact Phone No.: 209.951-6745 Make/Model of Monitoring System: Veeder Root T35-350R Date of Testing/Servicing: 10/12/2015 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment in cted serviced: Tank ID: T-1-RUL Tank ID: T-2-PUL r In-Tank Gauging Probe. Model: maq r In-Tank Gauging Probe. Model: map r Annular Space or Vault Sensor. Model: 427 r Annular Space or Vault Sensor. Model: 420 r Piping Sump/Trench Sensor(s). Model: 352 r Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: r_�Mechanical Line Leak Detector. Model: Red Jacket FXIV r Mechanical Line Leak Detector. Model: Vapodess LD-2000 J Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overtill/High-Level Sensor.Model: r Tank Overfill/High-Level Sensor.Model: other(specify equipment type and model in Section E on Pa e 2). r7 Other(specify equipment 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 Senscr(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: ❑ Electronic Line Leak Detector. Model: r Tank Overfill/High-Level Sensor.Model: r Tank Overfill/High-Level Sensor.Model: Other(specify equipment and model in Section E on Pae 21. Other(specify equipment and model in Section E on Pa 2). Dispenser 1/2 Dispenser 3/4 ID: ID: r Dispenser Containment Sensor(s).Model: 352 r Dispenser Containment Sensor(s).Model: 352 P Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). J Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s).Model: ❑Dispenser Containment Sensor(s).Model: r Shear Valve(s). ❑Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats and Chain(s). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s).Model: ❑Dispenser Containment Sensor(s).Model: r Shear Valve(s). ❑Shear Valve(s). r Dispenser Containment Floats and Chain(s). L7 Dispenser Containment Floats and Chain(s). *If the facility contains more tanks or dispensers,copy this form.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 anoW.r System set- up r Alarm history report Technician Name(print): Steve Willem; Signature: Certification No.: 836743 Llcense.No.: 743160 CI3ss'A' Testing Company Name: Tanknology Phone No.: (800)8004633 Testing Company Address: 11000 N.MoPac Expressway Suke 500 Date of Testing/Servicing: 10/12/2015 Monitoring System Certification Page 1 of 3 12/07