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• • RECEIVED Appendix VI OCT 0 4 2017 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hfp://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL HEALTH For Use By All Juni Within the State of California DEPARTMENT 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 certification or report must be prepared for each monitoring system control panel by the technician who performs the work.A ropy of this form 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: 95707 Facility Contact Person: MGR-SATBIR Contact Phone No.: 209-951-6745 Make/Model of Monitoring System: Veeder Root TLS-35OR Date of Testing/Servicing: 9/12/2017 B.Inventory of Equipment Tested/Certified Check the aDDrooriate boxes to indicatespecific equipment ins serviced: Tank ID: T-1-RUL Tank ID: T-2-PUL r In-Tank Gauging Probe. Model: MAG r In-Tank Gauging Probe. Model: MAG F-0 Annular Space or Vault Sensor. Model: 794390-420 r Annular Space or Vault Sensor. Model: 794390420 (v— Piping Sump/Trench Sensor(s). Model: 794380-352 r7. Piping Sump/Trench Sensor(s). Model: 794380-208 r Fill Sump Sensar(s). Model: r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: Red Jacket FXIV r7o Mechanical Line Leak Detector. Model: Vapodess LD-2000 r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor.Model: FLAPPERS P_ Tank Overfill/High-Level Sensor.Model: FLAPPERS Other(specify a ui ment type and model in Section E on Pae 2). r 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 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(specify equipment a and model in Section E on Pae 2). Other(sDecify equipment a and model in Section E on Page 2). Dispenser 1/2Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s).Model: 794380-352 r Dispenser Containment Sensor(s).Model: 794380-352 IV Shear Valve(s). F-0 Shear Valve(s). r Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Floats 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). Dispenser Containment Floats and Chain(s). Dispenser Containment Floats 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). Dispenser Containment Float(s)and Chain(s). 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):F-0 System set- up r Alarm history report Technician Name(print): Jesus Saldivar Signature: O "'---- Certification No.: B45334 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: 9/22/2017 Monitoring System Certification Page 1 of 3 12/07