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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION 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, 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 Facility Contact Person: MANAGER Make/Model of Monitoring System: Veeder Root TLS 350 B. Inventory of Equipment Tested/Certified rk-1, +6n k--.. +n c Afle —d—M. incn +ud 1—i—A. Contact Phone No.: 957-2900 Zip: 95209 Date of Testing/Servicing: 2/8/2013 Tank ID: T1: - RUL Tank ID: T2: - PUL r' In -Tank Gauging Probe. Model: MAG r7 In -Tank Gauging Probe. Model: MAG Annular Space or Vault Sensor. Model: 407 ry_� Annular Space or Vault Sensor. Model: 407 WO Piping Sump / Trench Sensor(s). Model: 208 ry-1'. Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: r, Fill Sump Sensor(s). Model: ryo Mechanical Line Leak Detector. Model: FE Petro MLD', Mechanical Line Leak Detector. Model: FE Petro MLD r— Electronic Line Leak Detector. Model: r- Electronic Line Leak Detector. Model: r'. Tank Overfill / High -Level Sensor. Model: FLAPPER Tank Overfill / High -Level Sensor. Model: FLAPPER Other(specify equipment a and model in Section E on Page 2). Other(specify equipment a and model in Section E on Pae 2). Tank ID: T3: - Diesel Tank ID: ; In -Tank Gauging Probe. Model: MAG r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 407 r Annular Space or Vault Sensor. Model: red" Piping Sump / Trench Sensor(s). Model: 208 ( Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Vaporless LD -2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Wo 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 3/4 ID: ID: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). 171 Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: rvOShear Valve(s). rV Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: r Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). 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 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):' System set- up W Alarm history report Technician Name (print): Jarrod Cooke Certification No.: B35255 Testing Company Name: Tanknology License. No. Signature:�� 743160 Class'A' Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 2/8/2013 Monitoring System Certification Page 1 of 3 12/07