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ONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of Calofmia Authority C hapter 6.7,Health and Safety Code;Chapter 16,Division a 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 insetted at the facility, aais_eparattee 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. I he 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#32262 Site Address: 2360 GRANTLINE, 1-205 OFF RAMP City: TRACY CA Zip:95376 MARKET#2237 Contact Phone No: 830-9917 Facilty Contact Person: CHANDRA Date of Testing/Service: 05/22/2001 Make/Model of Monitoring System:TIDEL EMS3500 Word Order Number: 2216856 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equipment inspected/serviced Tank ID: 1 Tank ID: 2 71 In-Tank Gauging Probe. Model: PRB2 In-Tank Gauging Probe. Model: PRB2 -59 Annular Space or vault Sensor. Model: 3010635 71 Annular Space or Vault Sensor. Model: 3010635 71 Piping Sump/Trench Sensor(s). Model: 3010642 Piping Sump/Trench Sensor(s). Model: 3010642 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: -39 Tank overfill/High-Level Sensor. Model: A1100 Tank Overfill/High-Level Sensor. Model: A1100 Dispenser Containment Sensor(s) Model: 3010642 Dispenser Containment Sensor(s) Model: 3010642 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 : 3 1 an . In-Tank Gauging Probe. Model: PRB2 In-Tank Gauging Probe. Model: -XlAnnular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: 71 Piping Sump/Trench Sensor(s). Model: 3010642 Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: LD2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: A1100 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: -59 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 1 certify that the equipment identified in this document was inspected(serv/ced in accordance with the manufacturer's guidelines. Attached to this certification is information(e.g manufacturers 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 JEFF CONGER '' ' jN PRINTED NAME: SIGNATURE: u COMPANY: Tanknology PHONE NO: (800)800-4633 page 1 of 3 Based on CA form dated 05/00