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RECEIVED Appendix VI SEP 2 8 2016 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATICMVIRONMENTAL HEALTH For Use By All Jurisdictions 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 copy 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 Facility Name: 7 -ELEVEN #19976, MKT 2368 Bldg. No.: Site Address: 1399 N. MAIN ST.@ NORTHGATE Facility Contact Person: BEN Contact Phone No.: 209-239-3252 Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified Check the annrnnriate hnYes to indicate snecific enuinment inspected/sprviced: City: MANTECA Zip: 95336 Date of Testing/Servicing: 9/19/2016 Tank ID: T4 - RUL Tank ID: T5 - PUL (d In -Tank Gauging Probe. Model: 846390-107 r7 In -Tank Gauging Probe. Model: 846390-107 I✓ Annular Space or Vault Sensor. Model: 794380-302 r Annular Space or Vault Sensor. Model: 794380-302 F Piping Sump / Trench Sensor(s). Model: 794380-208 rv—O Piping Sump / Trench Sensor(s). Model: 794380-208 W Fill Sump Sensor(s). Model: 794380-208 17 Fill Sump Sensor(s). Model: 794380-208 r Mechanical Line Leak Detector. Model: Vaporless LD -2000 r Mechanical Line Leak Detector. Model: Vaporless LD -2000 F Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: (7/ Tank Overfill / High -Level Sensor. Model: flapper r%_0 Tank Overfill / High -Level Sensor. Model: flapper Other(specify equipment a and model in Section E on Page 2). Other(specify equipment a and model in Section E on Pa e 2). Tank ID: Tank ID: r In -Tank Gauging Probe. Model: (— 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: F 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 Page 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Ii/ Dispenser Containment Sensor(s). Model: 794380-208 r,70 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). IV 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: F 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). *It the tacility contains more tanks or dispensers, copy this torm. Include information for every tank and tllspenser at the tacillty. 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): IV System set- up 507 Alarm history report Technician Name (print): Jeffrey Crisostomo Certification No.: 842876 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Signature License. No.: 743160 Ciass'A' Phone No.: (800) 800-4633 Page 1 of 3 Date of Testing/Servicing: 9/19/2016 12/07