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�J Appendix VI MAR 18 20114 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://rcb.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Califomia HEALTH 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 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 B. Inventory of Equipment Tested/Certified rhes if tha nnnAntes hnvac to ineiir to cnarife• anuinmant incnar+af11 rmieaele 2/27/2014 Tank ID: Tl: - RUL Tank ID: T2: - PUL r' In -Tank Gauging Probe. Model: mag W7 In -Tank Gauging Probe. Model: mag Annular Space or Vault Sensor. Model: 307 _e Annular Space or Vault Sensor. Model: 307 ' Piping Sump / Trench Sensor(s). Model: 208 W Piping Sump / Trench Sensor(s). Model: 208 rYl Fill Sump Sensor(s). Model: 208 o Fill Sump Sensor(s). Model: 208 ry Mechanical Line Leak Detector. Model: FE Petro MLD r++, Mechanical Line Leak Detector. Model: FE Petro MLD Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: flapper ry Tank Overfill / High -Level Sensor. Model: flapper ', Other(specify a ui ment a and model in Section E on Pae 2). Others iV equipment a and model in Section E on Pae 2). Tank ID: T3: - Diesel Tank ID: rV In -Tank Gauging Probe. Model: mag r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 307 r Annular Space or Vault Sensor. Model: ry Piping Sump / Trench Sensor(s). Model: 208 r Piping Sump / Trench Sensor(s). Model: W Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: ry-1 Mechanical Line Leak Detector. Model: Vaporless LD -2000 r Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: flapper 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 2T— .Dispenser Dispenser 1/2 Dispenser 7/8 ID: ID: r Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 17 Shear Valve(s). W Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r 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). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser ID: ID: Dispenser Containment Sensor(s). Model: 208 r Dispenser Containment Sensor(s). Model: r Shear Valve(s). 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 aispensers, copy tnis Corm. Incivae mtormation for every tanK ana aispenser at the racnay. 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): W System set- up P Alarm history report Technician Name (print): Brent Bowen Certification No.: 842815 Testing Company Name: Tanknology Signature: License. No.: 743160 Class'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Page 1 of 3 Date of Testing/Servicing: 2/27/2014 12/07