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MONITORING SYSTINIVI CERTIFICATION - W, age 1 Continuation MAKE I MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: January 16, 2013 Al. FACILITY A2. OWNER Name Tower Mart # 104 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 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) 131 (Continued): TANKS i� Tank #5 (Product): I FTa_nk #6 (Product): ❑ In -Tank Gau in Probe Model: ❑ In -Tank Gauging Probe Model: ❑ U g Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump! Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill 1 High -Level Sensor Model: 3❑ ❑ Other (specify equipment in Section E) Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensor(s) Model: El Fill Sump Sensors) Model: ❑ Mechanical Line Leak Detector Model: _ ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill 1 High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model Tank #7 (Product): Tank #8 (Product): ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensor(s) Model: ❑ Piping Sump I Trench Sensor(s) Model; ❑ Fill Sump Sensors) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model ❑ Tank Overfill1 High -Level Sensor Model: ❑ Tank Overfill f High -Level Sensor Model: El Other (specify equipment In Section E) Model Other (specify equipment in Section E) Model: 132: (Continued) DISPENSERSIUDC's Dispenser # : 13-14 Dispenser # : 15-16 ■ Dispenser Containment Sensors) Model: 0794380-208 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chaln(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : 17-18 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : 21-22 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chains) Dispenser # : 19-20 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : 23-24 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensors) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) lDispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chains) Page la of 3