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' MONIT(WING SYSTEM CERTIFWATION MAKE 1 MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: .January 16, 2013 Al. FACILITY A2. OWNER Name Tower Mart # 904 Name Tower Energy Group, Inc. Address 192 Lathrop Road, Lathrop, CA 95330 Address 1983 West 190th Street, Torrance, CA 90504 Phone # 209-858-4998 Phone # 916-285-7402 ext 100 Contact Desiz Burns Contact Mark Vasey A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Address P.O. Box 1025, W. Sacramento, CA 95691 Notified January 8, 2013 Lic # 617238 A, B, Haz Inspector Thuy Tran Contact Dulcinea Covan Phone # 209-468-8257 Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTEDICERTIFIED (Check the appropriate boxes to indicate equipment inspectedlserviced) E1: TANKS Tank #1 (Product): Gasoline - 87-1 Tank #2 (Product): Gasoline - 87-2 ❑ In -Tank Gauging Probe Model: ElIn-TankGauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390.420 j ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Piping Sump I Trench Sensor(s) Model: 0794380-208 ■ Piping Sump I Trench Sensor(s) Model: 0794380-208 ■ Fill Sump Sensor(s) Model: 0794380-208 ■ Fill Sump Sensors) Model: 0784380-208 ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ■ Electronic Line Leak Detector Model: 0848480.001 ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill I High -Level Sensor Model: ❑ Tank Overfill I High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): Gasoline - 91 Tank #4 (Product): Diesel In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390420 ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Piping Sump I Trench Sensor(s) Model: 0794380-208 ■ Piping Sump I Trench Sensors) Model: 0794380-208 ■ Fill Sump Sensor(s) Model: 0794380_-208 ■ Fill Sump Sensor{s) Model: 0794380-208 ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ■ Electronic Line Leak Detector Model: 0848480-001 ■ Electronic Line Leak Detector Model: 0848480-001 ❑ Tank Overfill 1 High -Level Sensor Model: ❑ Tank Overfill I High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: 132: DISPENSERSIUDC's Dispenser # : 1-2 Dispenser # : 3-4 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : 5-6 Dispenser # : 7-8 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Dispenser Containment Sensors) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chains) Dispenser # : 9-10 Dispenser # : 11-12 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) C. CERTIFICATION I certify that the equipment identified in this document was inspectedlserviced 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 ■ Alarm History Report Q WALTON Wa��~ Signature: ENGINEERING, INC. Technician I Cert M Jessie Wadkins I B35391 5307886 -UT Date: January 16, 2013 © 2013 Walton Engineering, Inc.