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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 14113, MKT 2368 Bldg , No. : MWED Site Address: 3040 BENJAMIN HOLT DR @ GRIGSBY City : STOCKTON Zip : 95219 Facility Contact Person: STORE MANAGER Contact Phone No. : 209.478-3040 Make/Model of Monitoring System : Veeder Root TLS-35011 Date of Testing/Servicing : 9/20/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment ins ected serviced: Tank ID: T1 - REGULAR Tank ID: F In-Tank Gauging Probe. Model : 847390409 r In-Tank Gauging Probe. Model : F Annular Space or Vault Sensor, Model : 794380-303 r Annular Space or Vault Sensor. Model : MNW R Piping Sump / Trench Sensor(s), Model : 794380-208 r Piping Sump / Trench Sensor(s). Model : r Fill Sump Sensor(s). Model : 794380-208 �' Fill Sump Sensor(s). Model : Mechanical Line Leak Detector. Model : Vaporiess LD-2000 Mechanical Line Leak Detector. Model : r Electronic Line Leak Detector. Model : r Electronic Line Leak Detector. Model : F40 Tank Overfill / High-Level Sensor. Model : E/A r Tank Overfill / High-Level Sensor. Model : r Other (specify equipment type and model in Section E on Pa e 2) . r Other (specify equipment a and model in Section E on Pae 2). Tank ID : T2 - SUPREME Tank ID : r In-Tank Gauging Probe. Model : 847390.109 �' In-Tank Gauging Probe. Model : W Annular Space or Vault Sensor. Model : 794380-303 r Annular Space or Vault Sensor. Model : FV Piping Sump / Trench Sensor(s). Model : 794380-208 1 Piping Sump / Trench Sensor(s) . Model : F Fill Sump Sensor(s). Model : 794380-208 r Fill Sump Sensor(s) . Model : F 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 : FV Tank Overfill / High-Level Sensor. Model : E/A r Tank Overfill / High-Level Sensor. Model: r Other (specify equipment type and model in Section E on Pa e 2). Other (specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 7/8 ID: ID: F Dispenser Containment Sensor(s). Model : 794380-208 IV Dispenser Containment Sensor(s). Model : 794380-208 r Shear Valve(s). Shear Valve(s). r Dispenser Containment Float(s) and Chain(s) . r Dispenser Containment Float(s) and Chain(s) . Dispenser 3/4 Dispenser ID: ID: Dispenser Containment Sensor(s), Model : 794380-208 r Dispenser Containment Sensor(s). Model : F Shear Valve(s). r Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). (+ Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser ID: ID: f7 Dispenser Containment Sensor(s). Model : 794380.208 r Dispenser Containment Sensor(s). Model : Shear Valve(s). r 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): FV System set- up W Alarm history report Technician Name (print) : Brent Bowen Signature: '2yh Certification No. : 842815 License. No. : 743160 Class 'A' Testing Company Name: Tanknology Phone No. : (800) 8004633 Testing Company Address : 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing : 9/20/2018 OWN Monitoring System Certification Page i of 4 12 / 07