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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.: 35355 Site Address: 3202 W HAMMER LANE City: STOCKTON Zip: 95209 Facility Contact Person: MANAGER Make/Model of Monitoring System: Veeder Root TLS 350 B. Inventory of Equipment Tested/Certified rhk fha sone nrioao hnvoa a,. inAir94o afe o.,..c.,..,e..t inenm.+m.r 1co i. A - Contact Phone No.: 957-2900 Date of Testing/Servicing: 2/23/2012 Tank ID: Tl: - RUL Tank ID: T2: - PUL In -Tank Gauging Probe. Model: MAG ry In -Tank Gauging Probe. Model: MAG r Annular Space or Vault Sensor. Model: 407 F Annular Space or Vault Sensor. Model: 407 Piping Sump / Trench Sensor(s). Model: 208 W: Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: FE Petro MLD fv_0 Mechanical Line Leak Detector. Model: FE Petro MLD Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: i✓ Tank Overfill / High -Level Sensor. Model: EXT ALRM/FLAPPER r%7 Tank Overfill / High -Level Sensor. Model: EXT ALRM/FLAPPER Other(specify equipment a and model in Section E on Pa e 2). 17, Other (specify equipment a and model In Section E on Pae 2). Tank ID: T3: - Diesel Tank ID: ry 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: W Piping Sump / Trench Sensor(s). Model: 208 F Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r,7 Fill Sump Sensor(s). Model: W Mechanical Line Leak Detector. Model: Vaporiess 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: EXT ALRM/FLAPPER Tank Overfill / High -Level Sensor. Model: 11 Other(specify equipment a and model in Section E on Pa e 2). r Other (SDecify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: r Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: W Shear Valve(s). 171, Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). f7 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: Shear Valve(s). Shear Valve(s). rV Dispenser Containment Float(s) and Chain(s)., Dispenser Containment Float(s) and Chain(s). Dispenser Dispenser ID: ID: r Dispenser Containment Sensor(s). Model: r Dispenser Containment Sensor(s). Model: Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r7 Dispenser Containment Float(s) and Chain(s). 'alt the tacility contains more tanks or dispensers, copy this Corm. include intormation for every tank ana aispenser at the Tacnity. 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): I System set- up Alarm history report Technician Name (print): Steven Willems Certification No.: 836743 Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Signature: License. No.: 743160 Class'A' Phone No.: (800) 800-4633 Page 1 of 3 Date of Testing/Servicing: 2/23/2012 12/07