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,RECRVED <br /> Afforda- 1 e t <br /> 4162"d Street <br /> OCT 2 2 2018 Galt, CA 95632 <br /> (209) 744-0113 Fax (209) 744-0116 <br /> EIVIRONMENTAL HEALTH <br /> R � IMo T <br /> Veeder-Root In-Station Diagnostics Site Shutdown Test Report Form <br /> Permit Number:N-714 Date of Test: 9/26/2018 Time: <br /> Site Name: FLAG CITY CHEVRON <br /> Site Address: 6421 CAPITOL AVENUE <br /> City: LODI, CA Zip: 95240 Technician: ZANE NIMMO <br /> Veeder-Root: A 28446 <br /> District: SJVAPCD <br /> ' SITE SHUTDOWN TEST' <br /> Test Parameter Test Result(Y/1) <br /> Was power removed from the TLS-350 console? Yes <br /> Was power to the submersible pump(s)removed by the TLS-350? Yes <br /> Was power restored to TLS-350 console? Yes <br /> COMMENTS(Include Description of Repairs Made) <br /> NOTES: 'A certified Veeder-Root technician must perform this test. <br /> 1 declare, under penalty of perjury under the laws of the state of California that based on information and beliefformed <br /> after reasonable inquiry, the statements and information provided in this document are true, accurate, and complete. <br /> Signature of Technician: Date: 9/26/2018 <br /> Vet. 1.0-09.18.08 <br />