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10 RECEIVED Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hftp://w".sw4a. )201 MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL HEALTH For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7, Health and Safety Code;Chapter 16,Division 3, Title 23, CalifDAWMEWNT 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 35355 Bldg.No.: Site Address: 3202 W HAMMER LANE City: STOCKTON Zip: 95209 Facility Contact Person: MANAGER Contact Phone No.: 209-957-2900 Make/Model of Monitoring System: Veeder Root TLS 350 Date of Testing/Servicing: 2/27/2014 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected serviced: Tank ID: T1:-RUL Tank ID: T2: -PUL In-Tank Gauging Probe. Model: mag ry In-Tank Gauging Probe. Model: mag Annular Space or Vault Sensor. Model: 407 ry Annular Space or Vault Sensor. Model: 407 Piping Sump/Trench Sensor(s). Model: 208 r' Piping Sump/Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208 r Fill Sump Sensor(s). Model: 208 Mechanical Line Leak Detector. Model: FE Petro MLD Mechanical Line Leak Detector. Model: FE Petro MLD Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor.Model: flapper Tank Overfill/High-Level Sensor.Model: flapper f Other(specify equipment a and model in Section E on Pae 2). Other(specify a ui ment type and model in Section E on Pae 2). Tank ID: T3:-Diesel Tank ID: 1710 In-Tank Gauging Probe. Model: mag r In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 407 Annular Space or Vault Sensor. Model: r' Piping Sump/Trench Sensor(s). Model: 208 r Piping Sump/Trench Sensor(s). Model: rV Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: r?i. Mechanical Line Leak Detector. Model: Vaporless LD-2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: rvol Tank Overfill/High-Level Sensor.Model: flapper Tank Overfill/High-Level Sensor.Model: Other(specify equipment a and model in Section.E on Pae 2). Other(specify equipment a and model in Section E on Pae 2 . Dispenser 1/2 Dispenser 7/8 ID: ID: r, Dispenser Containment Sensor(s).Model: 208 r' Dispenser Containment Sensor(s).Model: 208 Shear Valve(s). rYO Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Float(s)and Chain(s). Dispenser 3/4 Dispenser ID: ID: r' Dispenser Containment Sensor(s).Model: 208 r Dispenser Containment Sensor(s).Model: rV Shear Valve(s). r Shear Valve(s). 17, Dispenser Containment Float(s)and Chain(s). r Dispenser Containment Float(s)and Chain(s). Dispenser 5/6 Dispenser ID: ID: rV Dispenser Containment Sensor(s).Model: 208 r Dispenser Containment Sensor(s).Model: rkO Shear Valve(s). r Shear Valve(s). 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 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 Pian 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):1710 System set- up W Alarm history report Technician Name(print): Brent Bowen Signature: Certification No.: B42815 License.No.: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800)800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 2/27/2014 Monitoring System Certification Page 1 of 3 12/07