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RLOEIVEL, Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov& T 16 2015 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California RO N M ENTAL. Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, 77t/e 23, Ca/lfornl rrN (1FPAQT!IAcNT 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 FacilityName: 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 rh, it ri,o nnn—~rota h—c r„ inrfi�ra norifir a i.,.r, t i,< rtaei iia i-A - City: MANTECA Zip: 95336 Date of Testing/Servicing: 10/7/2015 Tank ID: T4 - RUL Tank ID: T5 - PUL F In -Tank Gauging Probe. Model: mag r In -Tank Gauging Probe. Model: mag F Annular Space or Vault Sensor. Model: 303 r Annular Space or Vault Sensor. Model: 303 r Piping Sump / Trench Sensor(s). Model: 208 r Piping Sump / Trench Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: Vaporless LD -2000 r 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: flapper r Tank Overfill / High -Level Sensor. Model: flapper Other(specify equipment t e and model in Section E on Pae 2). r Other(specify equipment a and model in Section E on Pae 2). Tank ID: Tank ID: n In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: r7 Annular Space or Vault Sensor. Model: J Annular Space or Vault Sensor. Model: C Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: r7 Fill Sump Sensor(s). Model: r7 Fill Sump Sensor(s). Model: [] Mechanical Line Leak Detector. Model: r7l Mechanical Line Leak Detector. Model: Electronic line Leak Detector. Model: J Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: J Tank Overfill J High Level Sensor. Model: r Other(specify equipment a and model in Section E on Page 2). r Other(specify equipment a and model in Section E on Page 2). Dispenser 1/2 Dispenser 3/4 ID: ID: jV Dispenser Containment Sensor(s). Model: 208 r Dispenser Containment Sensor(s). Model: 208 P , 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: j Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: 17 Shear Valve(s). r Shear Valve(s). 17 Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: ❑ Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r7 Shear Valve(s). r Shear Valve(s). 117 Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). -ir me racnity contains more tanKs or dispensers, copy mis corm. rnciuoe mrormauon ror every tanK ano aispenser at me racuity. 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): r System set- up R Alarm history report Technician Name (print): Jarrod Cooke Signature: Certification No.: 835255 License. No.: 743160 Gass 'A' Testing Company Name: Tanknology Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: Monitoring System Certification Page 1 of 3 10/7/2015 12/07