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MONIT ING SYSTEM CERTIVATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: June 28, 2013 A1. 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 Grossi A3. C U P A INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to indicate equipment Inspected/serviced) B1: TANKS A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Tank #1 (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 / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Address P.O. Box 1025, W. Sacramento, CA 95691 Notified June 26, 2013 Lic # 617238 A, B, Haz Inspector Garrett Backus Model: Model: Model: Model: Model: Model: Model: Model: 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 / 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: Tank #2 (Product): _ ❑ In -Tank Gauging Probe ❑ Annular Space or Vault Sensor ❑ Piping Sump / Trench Sensor(s) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment in Section E) Model: Model: Model: Model: Model: Model: Model: 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 / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Tank #4 (Product): ❑ In -Tank Gauging Probe ❑ Annular Space or Vault Sensor ❑ Piping Sump / Trench Sensor(s) j ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment in Section E) Model: Model: Model: Model: Model: Model: Model: Model: 132: DISPENSERS/UDC's Dispenser # : 1-2 ❑ 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 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 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 Signature: 0�(� 'G{^t(/ /�Q/J n , / q M WALTON ENGINEERING, INC. Technician / Cert #: Chris Kuykendall / B42243 8161927 Date: June 28, 2013