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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 #32262, MKT 2368 (N-3940-1 Bldg. No.: Site Address: 2360 W GRANTLINEI-205 OFF RAMP City: TRACY 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 Ch—1, M.n I-- to :nd:rotu -Ari, unci nmont i—n—t-11 /curvirorl• Zip: 95376 Date of Testing/Servicing: 3/3/2016 Tank ID: Tank ID: In -Tank Gauging Probe.. Model: In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: Piping Sump /Trench Sensor(s). Model: r7 Piping Sump / Trench Sensor(s). Model: r; Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: 17 Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r7. Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment t e and model in Section E on Pae 2). Tank ID: Tank ID: In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ri Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: [ i Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s). Model: r� Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: s Tank Overfill / High -Level Sensor. Model: r Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pa2e 2). r Other(specify equipment a and model in Section E on Pa2e 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s). Model: 784380-352 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). Dispenser 5/6 Dispenser 7/8 ID: ID: ry Dispenser Containment Sensor(s). Model: 784380-352 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). Dispenser 9/10 Dispenser 11/12 ID: ID: 17 Dispenser Containment Sensor(s). Model: 784380-352 We Dispenser Containment Sensor(s). Model: 784380-352 Pr, Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). [ Dispenser Containment Float(s) and Chain(s). *It the tacility contains more tanks or dispensers, copy this Corm. Include intormation for every tank and oispenser at the taality. 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 P Alarm history report Technician Name (print): Nicolas Poblano Certification No.: 845361 License. No.: Testing Company Name: Tanknology Testing Company Address: 11000 N. MoPac Expressway Suite 500 Monitoring System Certification Signature: 743160 Class 'A' Phone No.: (800) 800-4633 Page 2 of 4 Date of Testing/Servicing: 3/3/2016 12/07