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MONITC#ING SYSTEM CERTIWATION MAKE / MODEL OF MONITORING SYSTEM: Gilbarco EMC CERTIFICATION /TEST DATE: December 3, 2009 A1. FACILITY Name Olympian # 427 Address 3300 Waterloo Road, Stockton, CA 95205 Phone # 530-885-0401 Contact Amanda Appelt A2. OWNER Name Nella Oil Company, LLC Address 2360 Lindbergh Street, Auburn, CA 95602 Phone # 530-885-0401 Contact Amanda Appelt A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #1 (Product): Gasoline - 87 Name Walton Engineering, Inc. Address 600 E. Main Street , Stockton, CA 95202 In -Tank Gauging Probe Address P.O. Box 1025, W. Sacramento, CA 95691 Notified November 19, 2009 ■ Lic # 617238 A, B, Haz Inspector Jeffrey Wong Model: 0794390-420 Contact Richard Walton Phone # 209-468-3439 Piping Sump / Trench Sensor(s) Phone # 916-825-3203 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to indicate equipment inspected/serviced) ❑ B1: TANKS ■ 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 WALTON Signature: ENGINEERING, INC. I( Technician / Cert #: Jessie Wadkins I B35391 5307886 -UT Date: Deceinber 3, 2009 11 Dispenser # : 1 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 2 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Tank #1 (Product): Gasoline - 87 Tank #2 (Product): Red Diesel ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Piping Sump I Trench Sensor(s) Model: 0794380-208 ■ Piping Sump / Trench Sensor(s) Model: 0794380-205 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: FE Petro STP -MLD ■ 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: ❑ 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: VMI 99LD-2000 ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ 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: 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 WALTON Signature: ENGINEERING, INC. I( Technician / Cert #: Jessie Wadkins I B35391 5307886 -UT Date: Deceinber 3, 2009 11 Dispenser # : 1 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 2 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 5 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser ❑ ■ ■ # : 3-4 Dispenser Containment Sensor(s) Model: Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : 8 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 7 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ 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 WALTON Signature: ENGINEERING, INC. I( Technician / Cert #: Jessie Wadkins I B35391 5307886 -UT Date: Deceinber 3, 2009 11