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MONITORING SYSTEM CERTIFICATION '"' AM For Use By All Jurisdictions WRhin the State of Calofmi Authority Chapter 6.7,Health and Safety Code;Chapter 16,Divisio tle 23,California Code of Regulations This Form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is insalled at the facility, a separate certification or report must be prepared for each monitring 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 tot the local agency regulating UST systems within 30 days of test date. Instructions are printed on the back page. A. General Information Facility Name: 7-ELEVEN#20632 MKT 2237 Site Address: 4627 DA VINCI DR. City: STOCKTON CA Zip:95207 @ MARCH LN. Contact Phone No: 952-3543 Facilty Contact Person: MGR-SATBIR Date of Testing/Service: 06/25/2001 Make/Model of Monitoring System:VR TLS350R Word Order Number: 2217378 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced Tank ID: 1 Tank ID: 2 -59 In-Tank Gauging Probe. Model: 847390107 71 In-Tank Gauging Probe. Model: 847390107 71 Annular Space or Vault Sensor. Model: 794390420 71 Annular Space or Vault Sensor. Model: 794390420 71 Piping Sump/Trench Sensor(s). Model: 794380352 71 Piping Sump/Trench Sensor(s). Model: 794380352 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: 71 Mechanical Line Leak Detector. Model: LD2000 Mechanical Line Leak Detector. Model: LD2000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: ,71 Tank Overfill/High-Level Sensor. Model: 61 SO 71 Tank Overfill/High-Level Sensor. Model: 61 SO Dispenser Containment Sensor(s) Model: 794380352 Model: 794380352 -39 p Dispenser Containment Sensor(s) Shear Valve(s). 71 Shear Valve(s). Dispenser Containment Float(s)and Chains(s). Dispenser Containment Float(s)and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). an 15HRID: In-Tank Gauging Probe. Model: In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 7Annular 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: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s)and Chains(s). Dispenser Containment Float(s)and Chains(s). Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). C. Certification /certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this certification is information(e.g manufacturer's checklists)necessary to verify that this information is correct and a Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,1 have also attached a copy of the(Check all that apply): System set-up report; ® Alarm history report PRINTED NAME: JEFF CONGER SIGNATURE: COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 05/00