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RECEIVED GAZ013 U Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at hftp://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, 771tle 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 Date of Testing/Servicing: 3/2/2018 B.Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicate specific equipment inspected/serviced: Tank ID: T4 RUL-REG UNLEAD Tank ID: T5 MUL-MIDGRADE rv� In-Tank Gauging Probe. Model: MAG ire, In-Tank Gauging Probe. Model: MAG W Annular Space or Vault Sensor. Model: 794380-302 r7l, Annular Space or Vault Sensor. Model: 794380-302 W Piping Sump/Trench Sensor(s). Model: 794380-352 r Piping Sump/Trench Sensor(s). Model: 794380-352 W; Fill Sump Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: 794380-208 r Mechanical Line Leak Detector. Model: Vaporless LD-2000 r Mechanical Line Leak Detector. Model: Vaporless LD-2000 r Electronic Line Leak Detector. Model: 17 Electronic Line Leak Detector. Model: FY7 Tank Overfill/High-Level Sensor.Model: FLAPPERS Tank Overfill/High-Level Sensor.Model: FLAPPERS r r— Other(specify equipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Page 2). Tank ID: T6 PUL-PREMIUM Tank ID: In-Tank Gauging Probe. Model: MAG riIn-Tank Gauging Probe. Model: ry', Annular space or Vault Sensor. Model: 794380-302 Annular Space or Vault Sensor. Model: W Piping Sump/Trench Sensor(s). Model: 794380-352 r Piping Sump/Trench Sensor(s). Model: W Fill Sump Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: d. Mechanical Mechanical Line Leak Detector. Model: Vaporless LD-2000 Mechanical Line Leak Detector. Model: r Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: riv!_Tank Overfill/High-Level Sensor.Model: FLAPPERS Tank Overfill/High-Level Sensor.Model: Other(specify equipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Page 2). Dispenser 1/2 Dispenser 3/4 ID: ID: Dispenser Containment Sensor(s).Model: 794380-352 rv_ Dispenser Containment Sensor(s).Model: 794380-352 r- Shear Valve(s). rY7 Shear Valve(s). r7 Dispenser Containment Float(s)and Chain(s). 17 Dispenser Containment Float(s)and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: Dispenser Containment Sensor(s).Model: 794380-352 r.7 Dispenser Containment Sensor(s).Model: 794380-352 rv_� 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: rv� Dispenser Containment Sensor(s).Model: 794380-352 W Dispenser Containment Sensor(s).Model: 794380-352 ro_o� Shear Valve(s). Shear Valve(s). r— Dispenser Containment Float(s)and Chain(s), r—, Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility. 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 r Alarm history report Technician Name(print): Jesus Saldivar Signature: Certification No.: B45334 License.No.: 743160 Class Testing Company Name: Tanknology Phone No.: (800)800-4633 Testing Company Address: 11000 N.MoPac Expressway Suite 500 Date of Testing/Servicing: 3/2/2018 Monitoring System Certification Page 1 of 3 12/07