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MONITORING SYSTEM CERTIFMATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: September 2.2014 Al. FACILITY A2. OWNER Name 7 -Eleven Market #2369 / Store #35355 Tank #1 (Product): Gasoline - 87 Name 7 -Eleven, Inc Address 3202 W. Hammer Lane, Stockton, CA 95209 In -Tank Gauging Probe Address P.O. Box 711, Dallas, TX 75221 Phone # 209-957-2900 ■ Phone # 805-523-2949 Contact Stephen Boyd Model: 0794390.409 Contact Stephen Boyd A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #1 (Product): Gasoline - 87 Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 In -Tank Gauging Probe Address P.O. Box 1025, W. Sacramento, CA 95691 Notified August 29, 2014 ■ Lic # 617238 A, B, Haz Inspector Elena Manzo Model: 0794390.409 Contact Dulcinea Covan Phone # 209-468-8257 Piping Sump / Trench Sensor(s) Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to Indicate equipment Inspected/serviced) Rt• TANKC CS7_ U11M1-N1FK\/111 )[ ='C Dispenser # : 1-2 Dispenser # : 3-4 Tank #1 (Product): Gasoline - 87 Dispenser Containment Sensor(s) Model: 0794380-208 Tank #2 (Product): Gasoline - 91 Dispenser Containment Sensor(s) Model: C 794380.208 ■ In -Tank Gauging Probe Model: 0847390-109 ■ In -Tank Gauging Probe Model: 0847390-109 ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Annular Space or Vault Sensor Model: 0794390.409 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ■ Fill Sump Sensor(s) Model: 0794380-208 ■ Fill Sump Sensor(s) Model: 0794380-208 ❑ 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: 0847390-109 ■ Tank Overfill/ High -Level Sensor Model: 0847390-109 ❑ Other (specify equipment In Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): Diesel Tank #4 (Product): ■ In -Tank Gauging Probe Model: 0847390-109 ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-409 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Piping Sump / Trench Sensor(s) Model: ■ Fill Sump Sensor(s) Model: 0794380-208 ❑ 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: 0847390-109 ❑ Tank Overfill/ High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: CS7_ U11M1-N1FK\/111 )[ ='C 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 verity that this information Is correct and a Plot Plan 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 Histo Report •- W J� WALTON OVa+" a Signature: ENGINEERING, INC. Technician / Cert #: Jessie Wadkins 1 B35391 5307886 -UT Date: September 2, 2014 Dispenser # : 1-2 Dispenser # : 3-4 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Dispenser Containment Sensor(s) Model: C 794380.208 ■ 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: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(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' guidelines. Attached to this Certification is Information (e.g. manufacturers' checklists) necessary to verity that this information Is correct and a Plot Plan 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 Histo Report •- W J� WALTON OVa+" a Signature: ENGINEERING, INC. Technician / Cert #: Jessie Wadkins 1 B35391 5307886 -UT Date: September 2, 2014