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MONIT(WING SYSTEM CERTIWATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: Mav 23, 2013 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 Grossi A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #1 (Product): _ Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 In -Tank Gauging Probe Address P.O. Box 1025, W. Sacramento, CA 95691 Notified May 22, 2013 ❑ Lic # 617238 A, B, Haz Inspector None Model: Contact Dulcinea Covan Phone # 209-468-8257 Piping Sump / Trench Sensor(s) Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to indicate equipment inspected/serviced) B1 - TANKS :qm 01 KI :I:+.f/l l 111104117 Dispenser # : 1-2 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser ❑ ❑ ❑ Tank #1 (Product): _ 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: ❑ 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 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: 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: :qm 01 KI :I:+.f/l l 111104117 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 ��_ WALTON Signature: (//`! ••L ENGINEERING, INC. Technician / Cert #: Andrew Schnidt / B41610 ICC00053144 Date: May 23, 2013 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 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 ��_ WALTON Signature: (//`! ••L ENGINEERING, INC. Technician / Cert #: Andrew Schnidt / B41610 ICC00053144 Date: May 23, 2013