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v Appendix VI n (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 #32262, MKT 2368 (N-3940-1 Bldg. No.: Site Address: 2360 W GRANTLINEI-205 OFF RAMP City: TRACY Zip: 95376 Facility Contact Person: CHANDRA Contact Phone No.: 209-830-9917 Make/Model of Monitoring System: Veeder Root TLS-35OR B. Inventory of Equipment Tested/Certified ('hark the annrnnrintl hn— to inrlirntP cnPrifr PnllinmPnY incnarrP.l /mrvirPA Date of Testing/Servicing: 3/3/2016 Tank ID: T4 RUL - REG UNLEAD Tank ID: T5 MUL - MIDGRADE In -Tank Gauging Probe. Model: Mag 17 In -Tank Gauging Probe. Model: Mag Pr Annular Space or Vault Sensor. Model: 794380-302 Pr Annular Space or Vault Sensor. Model: 794380-302 Piping Sump / Trench Sensor(s). Model: 784380-3521 Piping Sump / Trench Sensor(s). Model: 784380-352 + Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: 794380-208 P Mechanical Line Leak Detector. Model: Vaporless LD -2000 W Mechanical Line Leak Detector. Model: Vaporless LD -2000 Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Pr Tank Overfill / High -Level Sensor. Model: flapper Pr Tank Overfill / High -Level Sensor. Model: flapper s Other(specify equipment t e and model in Section E on Pa r Other(specify equipment t e and model in Section E on Page 2). Tank ID: T6 PUL - PREMIUM Tank ID: jJ, In -Tank Gauging Probe. Model: Mag r In -Tank Gauging Probe. Model: Pr Annular Space or Vault Sensor. Model: 794380-302 r Annular Space or Vault Sensor. Model: 17, Piping Sump / Trench Sensor(s). Model: 784380-352 Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: Pr Mechanical Line Leak Detector. Model: Vaporless LD -2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Pr Tank Overfill / High -Level Sensor. Model: flapper , Tank Overfill / High -Level Sensor. Model: Other(specify equipment t e and model in Section E on Page r Other(specify a ui ment type and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s). Model: 784380-352 __,! Dispenser Containment Sensor(s). Model: 784380-352 W, Shear Valve(s). Pr Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r; Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: 17 Dispenser Containment Sensor(s). Model: 784380-352 Pr Dispenser Containment Sensor(s). Model: 784380-352 W Shear Valve(s), P Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s). Model: 784380-352 P11 Dispenser Containment Sensor(s). Model: 784380-352 Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). -ir the raciiity contains more tanKs or aispensers, copy tins rorm. rncivae mrormation for every tanK ana aispenser at the tacility. 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 Pr Alarm history report Technician Name (print): Certification No.: 84536: Nicolas Poblano License. No. Signature: 743160 Class'A' Testing Company Name: Tanknology Phone No.: (800) 800-4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: Monitoring System Certification Page 1 of 4 3130016