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MONIT4BRING SYSTEM CERTIOCATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION / TEST DATE: June 5, 2012 Al. FACILITY Name CRLLC #2705446 Address 1403 Country Club Blvd., Stockton, CA 95204 Phone # 209-943-2082 Contact Roger Fernandez A2. OWNER Name Pacific Convenience and Fuels, LLC Address 7108 Koll Center Pkwy, Ste 100, Pleasanton, CA 94566 Phone # 925-884-0827 Contact Tony Gross! A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #1 (Product): Diesel 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 May 30, 2012 ❑ Lic # 617238 A, B, Haz Inspector Garrett Backus Model: Contact Dulcinea Covan Phone # 209468-8257 Piping Sump / Trench Sensor(s) Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B7: TANKS 1:941111111191 KI J =1: K-14:f.`l/ III Iloin Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ❑ ❑ ❑ Tank #1 (Product): Diesel Tank #2 (Product): ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ 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: ❑ 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): _ Tank #4 (Product): _ ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump / Trench Sensor(s) Model: _ ❑ 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: ❑ Other (specify equipment in Section E) Model: 1:941111111191 KI J =1: K-14:f.`l/ III Iloin 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 Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, l have also attached a copy of the report; (check all that apply): ❑ System set-up ■ Alarm History Report + ' U1 1 , WU` WALTON Signature: oV�ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: ,Jane S, 2012 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 Cl 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) 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 Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, l have also attached a copy of the report; (check all that apply): ❑ System set-up ■ Alarm History Report + ' U1 1 , WU` WALTON Signature: oV�ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: ,Jane S, 2012