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r -- MONIT019ING SYSTEM CERTIFICATION TOW F MAKE/MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 NOV 0 9 2015 CERTIFICATION/TEST DATE: October 28, 2015 A1. FACILITY A2. OWNER I-IFAIoTAACRIT Name 7-Eleven Market#2369/Store#35355 Name 7-Eleven,Inc Address 3202 W.Hammer Lane,Stockton,CA 95209 Address P.O.Box 711,Dallas,TX 75221 Phone# 209-957-2900 Phone# 805-523-2949 Contact Stephen Boyd Contact Stephen Boyd A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering,Inc. Address 1868 E.Hazelton Avenue,Stockton,CA 95202 Address P.O.Box 1025,W.Sacramento,CA 95691 Notified 0 Lic# 617238 A,B,Haz Inspector Fatinah Zareef Contact Veronica Freitas Phone# 209-468-8257 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to Indicate equipment Inspected/serviced) B1: TANKS Tank#1 (Product): _ Tank#2 (Product): _ ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump/Trench Sensor(s) Model: ❑ Piping Sump/Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Other (specify equipment In Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank#3 (Product): Tank#4 (Product): _ ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump/Trench Sensor(s) Model: ❑ Piping Sump/Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: 62: DISPENSERS/UDC's Dispenser#: Dispenser# ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) Dispenser#: 5-6 Dispenser#: 7-8 Dispenser Containment Sensor(s) Model: 0794380-208 Dispenser Containment Sensor(s) Model: 0_7943_80-208_ M Shear Valves Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chaln(s) Dispenser#: Dispenser# ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) C. CERTIFICATION I certify that the equipment Identified in this document was inspected/serviced in accordance with the manufacturers'guldelines. Attached to this Certification Is Information(e.g.manufacturers'checklists)necessary to verify that this Information is correct and a Plot Pian showing th 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 ❑ System set-up ❑ Alarm History Report /J WALTON Signature: ENGINEERING,INC, Technician/Cert#: Curtis Carpenter/B37258 8020679 Date: October 28, 2015 5 Walton Engineering,Inc.