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MONITORING SYSTEM CERTIOZATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION / TEST DATE: September 12, 2012 Al. FACILITY A2. OWNER Name Tracy 76 - Reliance Gas Investments, Inc. Name Jivtesh Gill Address 2420 W. Grantline Road, Tracy, CA 95337 Address 4855 South State Hwy 99, Stockton, CA 95215 Phone# 209-948-2438 Phone# 209-948-2438 Contact Jivtesh Gill Contact Jivtesh Gill 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 September 11, 2012 Lic # 617238 A, B, Haz Inspector Thuy Tran Contact Dulcinea Covan Phone # 209-468-8257 Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS Tank #1 (Product): Gasoline - 87 Tank #2 (Product): Gasoline-91 ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0784380-420 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) Model: 0794380-205 ❑ Fill Sump Sensor(s) Model: ■ Piping Sump / Trench Sensor(s) Model: 0784380-205 ❑ 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 Overfill / High-Level Sensor Model: ❑ Tank Overfill / High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): Diesel Tank #4 (Product): ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-420 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) Model: 0794380-205 ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) 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 Overfill / High-Level Sensor Model: ❑ Tank Overfill / High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: I ❑ Other (specify equipment in Section E) Model: 62: DISPENSERS/UDC's Dispenser # : Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chaln(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chaln(s) Dispenser # : Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chaln(s) ❑ Dispenser Containment Float(s) and Chaln(s) 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): ■ System set-up ■ Alarm Histo Report /�J WALTON </ (�J' Signature: ENGINEERING, INC. Technician / Cert #: Juan Jauregui B35393 /5246964-UT Date: September 12, 2012 © 2012 Walton Engineering, Inc.