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0 RECEIVE# NAR Z 17 Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL HEALTH For Use By All Jurisdictions Within the State of California DEPARTMENT 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 Facility Contact Person: CHANDRA Contact Phone No. Make/Model of Monitoring System: Veeder Root TLS -350R B. Inventory of Equipment Tested/Certified rhark tho annrnnrinto havoc to indirato cnorifir a—inmont incnnrtnri rcamirod- City: TRACY 209-830-9917 Zip: 95376 Date of Testing/Servicing: 3/3/2017 Tank ID: T4 RUL - REG UNLEAD Tank ID: T5 MUL - MIDGRADE r In -Tank Gauging Probe. Model: 846390-107 In -Tank Gauging Probe. Model: 846390-107 r Annular Space or Vault Sensor. Model: 794380-302 r' Annular Space or Vault Sensor. Model: 794380-302 17 Piping Sump / Trench Sensor(s). Model: 794380-352 PF Piping Sump / Trench Sensor(s). Model: 794380-352 r Fill Sump Sensor(s). Model: 794380-208 r Fill Sump Sensor(s). Model: 794380-208 r Mechanical Line Leak Detector. Model: Vaporless LD -2000 I Mechanical Line Leak Detector. Model: Vaporless LD -2000 Electronic Line Leak Detector. Model: r Electronic Line Leak Detector. Model: r Tank Overfill / High -Level Sensor. Model: FLAPPERS Tank Overfill / High -Level Sensor. Model: FLAPPERS Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Tank ID: T6 PUL - PREMIUM Tank ID: In -Tank Gauging Probe. Model: 846390-107 In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794380-302 __ r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 794380-352 r Piping Sump / Trench Sensor(s). Model: v Fill Sump Sensor(s). Model: 794380-208 Fill Sump Sensor(s). Model: d; Mechanical Line Leak Detector. Model: Vaporless LD -2000 Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: FLAPPERS Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 3/4 ID: ID: PF Dispenser Containment Sensor(s). Model: 794380-352 rV7 Dispenser Containment Sensor(s). Model: 794380-352 Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). 17, Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 7/8 ID: ID: PF Dispenser Containment Sensor(s). Model: 794380-352 �' Dispenser Containment Sensor(s). Model: 794380-352 Shear Valve(s). rqeF 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: Dispenser Containment Sensor(s). Model: 794380-352 Dispenser Containment Sensor(s). Model: 794380-351 Shear Valve(s). Shear Valve(s). [! Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). -It the tacnity contains more tanKs or dispensers, copy tnis torm. Include mtormation for every tanK and dispenser 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): r%7 System set- up rV7 Alarm history report Technician Name (print): Jesus Saldivar Certification No.: 845334 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 i of 3 Date of Testing/Servicing: 3/3/2017 12/07