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Appendix VI QQ QV E D (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at h / IL4.0 MONITORING SYSTEM CERTIFICATION OCT 17 2016 For Use By All Jurisdictions Within the State of California q��tp Aut ho Regulations El... Chapter 6.7,Health and Safety Code;Chapter 16,Division 3, Title 23,California C I AL HEALTH ,,AA TMENT This form must be used to document testing and servicing of monitoring equipment.A separate certification or report must be p p r 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 Facility Name: 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.: 209-9516745 Make/Model of Monitoring System: Veeder Root TLS-350R Date of Testing/Servicing: 10/5/2016 B.Inventory of Equipment Tested/Cerdfied Check the appropriate boxes to indicatespecific equipment ins ected serviced: Tank ID: T-1-RUL Tank ID: T-2-PUL I7o In-Tank Gauging Probe. Model: 846390-107 r In-Tank Gauging Probe. Model: 846390-107 V Annular Space or Vault Sensor. Model: 794390420 IV Annular Space or Vault Sensor. Model: 794390420 174 Piping Sump/Trench Sensor(s). Model: 794380-352 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: Red Jacket FXSV Mechanical Line Leak Detector. Model: Vaporless LD-2000 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 and model in Section E on Page 2). Other(specify equipment 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 Senscr(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 type 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: 794380-352 rI Dispenser Containment Sensor(s).Model: 794380-352 Pr Shear Valve(s). WO Shear Valve(s). r Dispenser Containment Float(s)and Chaln(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). 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 forth.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 apply):Pr System set- up Pr Alarm history report Technician Name(print): Steve Willems Signature: �XXI Certification No.: 836743 License.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)8004633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 10/5/2016 Monitoring System Certification Page 1 of 3 12/07