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' MONITO&ING SYSTEM CERTI*ATCEIVED MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -35 CERTIFICATION /TEST DATE: July 23. 2014 I, „ _ A1. FACILITY A2. OWNER Name Flyers # 487 Name Flyers EnergAMRONMENT Address 983 Moffat Blvd., Manteca, CA 95336 Address 2360 Lindbergh Street, EALTH Phone # 530-885-0401 Phone # 530-885-0401 11111//11 (�T Contact Amanda Appelt Contact Amanda Appelt A3. C U P A INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #2 (Product): Gasoline - 91 Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Annular Space or Vault Sensor Model: 0794390-420 Address P.O. Box 1025, W. Sacramento, CA 95691 Notified July 8, 2014 ❑ Lic # 617238 A, B, Haz Inspector Elena Manzo ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): Diesel 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: 0794390-420 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ■ ❑ ❑ Mechanical Line Leak Detector Model: VMI 99LD-2000 ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 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: Tank #3 (Product): Diesel ❑ Other (specify equipment in Section E) Model: 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: 0794380-208 ❑ Piping Sump / Trench Sensor(s) Model: ❑ ■ ❑ ❑ ❑ Fill Sump Sensor(s) Model: Mechanical Line Leak Detector Model: VMI 99LD-2000 Electronic Line Leak Detector Model: Tank Overfill / High -Level Sensor Model: Other (specify equipment in Section E) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: 62: DISPENSERS/UDC'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 Sensor(s) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : 8 Sat Dispenser # ■ Dispenser Containment Sensor(s) Model: 0794380-208 ❑ Dispenser Containment Sensor(s) Model: ■ 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 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 History Report W Q n WALTON Signature: a� ENGINEERING, INC. Technician I Cert #: Jessie Wadkins / B35391 5307886 -UT Date: July 23, 2014