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MONITNING SYSTEM CERTIMATIMC7 mv...CEIVED MAKE / MODEL OF MONITORING SYSTEM: Gilbarco EMC CERTIFICATION /TEST DATE: July 16, 2014 11 11 Q CP 9n4A Al. FACILITY ❑ in -Tank Gauging Probe A2. OWNER Name Flyers # 427 ❑ Piping Sump I Trench Sensor(s) Name Flyers Energy VIRONMENTAL HEALT Address 3300 Waterloo Road, Stockton, CA 95205 Model: Address 2360 Lindbergh Street, AH�NT Phone# 530-885-0401 ❑ Other (specify equipment in Section E) Phone# 530-885-0401 Contact Amanda Appelt Tank Overfill I High -Level Sensor Contact Amanda Appelt A3. C U P A ❑ in -Tank Gauging Probe A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health ❑ Piping Sump I Trench Sensor(s) Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Model: Address P.O. Box 1025, W. Sacramento, CA 95691 Notified July 14, 2014 ❑ Other (specify equipment in Section E) Lic # 617238 A, B, Haz Inspector Jeff Wong Tank Overfill I High -Level Sensor 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): ❑ in -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill I High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): ❑ in -Tank Gauging Probe 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 I High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Tank #2 (Product): ❑ In -Tank Gauging Probe 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 I High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Tank #4 (Product): _ ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensor(s) 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: 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 Jij WALTON Signature: ENGINEERING, INC. Technician I Cert #: Chris Kuykendall / B42243 8161927 Date: July 16, 2014 Dispenser # : 6 ❑ Dispenser Containment Sensor(s) Model: M 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 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) 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 Jij WALTON Signature: ENGINEERING, INC. Technician I Cert #: Chris Kuykendall / B42243 8161927 Date: July 16, 2014