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RECEIVED Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://WWW.M'OM ENTAL MONITORING SYSTEM CERTIFICATION HEALTH DEPARTMENT 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 -350R Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified f`M�4 H.0 oFn I.w..n� Fw iniiineFn c e. -:s:.• u.. ..r : ..n.+n.i r�n...i.•n.l• 3/3/2016 Tank ID: T4 RUL - REG UNLEAD Tank ID: T5 MUL - MIDGRADE r In -Tank Gauging Probe. Model: Mag r In -Tank Gauging Probe. Model: Mag r Annular Space or Vault Sensor. Model: 794380-303 16,1-- r Annular Space or Vault Sensor. Model: 794380-303 S612_- — r Piping Sump / Trench Sensor(s). Model: 784380-352 r Piping Sump / Trench Sensor(s). Model: 784380-352 �i Fill Sump Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: 794380-208 Mechanical Line Leak Detector. Model: Vaporless LD -2000 r Mechanical Line Leak Detector. Model: Vaporless LD -2000 r Electronic Line Leak Detector. Model: r• Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: Flapper r Tank Overfill / High -Level Sensor. Model: flapper Other(specify equipment and model in Section E on Pa r Other(specify equipment a and model in Section E on Pa e 2). Tank ID: T6 PUL - PREMIUM Tank ID: In -Tank Gauging Probe. Model: r In -Tank Gauging Probe. Model: Mag r Annular Space or Vault Sensor. Model: 794380-303 Annular Space or Vault Sensor. Model: r Piping Sump / Trench Sensor(s). Model: 784380-352 r Piping Sump / Trench Sensor(s). Model: r Fill Sump Sensor(s), Model: 794380-208 r Fill Sump Sensor(s). Model: r Mechanical Line Leak Detector. Model: Vaporless LD -2000 r Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: flapper r< Tank Overfill / High -Level Sensor. Model: ,° Other(specify equipment a and model in Section E on Pa r Other(specify equipment a and model in Section E on Page 2). Dispenser 1/2 Dispenser 3/4 ID: ID: r Dispenser Containment Sensor(s). Model: 784380-352 r Dispenser Containment Sensor(s). Model: 784380-352 r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). j! Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: r Dispenser Containment Sensor(s). Model: 784380-352 r Dispenser Containment Sensor(s). Model: 784380-352 r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 9/10 Dispenser 11/12 ID: ID: r Dispenser Containment Sensor(s). Model: 784380-352 r Dispenser Containment Sensor(s). Model: 784380-352 r Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). -it me racWry concalns more canes or alspensers, copy mis Form. 1ncivae Inrurmduun For every CdnK ane uispenseF dL the idcuuy. 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): r System set- up rAlarm history report Technician Name (print): Nicolas Poblano Certification No.: 845361 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 4 Date of Testing/Servicing: 3/3/2016 12/07