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MONITORING SYSTEM CERTIFICA MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 T 1 2 Z�17 CERTIFICATION / TEST DATE: September 19, 2017 Al. FACILITY A2. OWNER C �.� oNMENTAL Name Colonial Energy#40135 Name Colonial Energyy-L�L ��RTMENT Address 192 Lathrop Road,Lathrop,CA 95330 Address 2860 N.Santiago Blvd.2nd range,CA 92867 Phone# 209-858-4998 Phone# 714-761-5426 Contact Station Manager Contact Victor Hassan A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering,Inc. Address 1868 E.Hazelton Avenue,Stockton,CA 95202 Address P.O.Box 1025,W.Sacramento,CA 95691 Notified 091917 Lic# 617238 A,B,Haz Inspector None Contact Veronica Freitas Phone# 209-468-3442 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) Bi: TANKS Tank#1 (Product): Gasoline-87-1 Tank#2 (Product): Gasoline-87-1_ ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: Annular Space or Vault Sensor Model: 794390-460 Annular Space or Vault Sensor Model: 794390-460 Piping Sump/Trench Sensors) Model: 0794380-208 Piping Sump/Trench Sensors) Model: 0794380-208 Fill Sump Sensors) Model: 0794380-208 Fill Sump Sensor(s) Model: 0794380-208 ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: 0 Electronic Lina Leak Detector Model: 0848480-001 N Electronic Line Leak Detector Model: 0848480-M ❑ 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): Gasoline-91 Tank#4 (Product): Diesel ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: Annular Space or Vault Sensor Model: 794390-460 Annular Space or Vault Sensor Model: 794390-460 Piping Sump/Trench Sensor(s) Model: 0794380.208 Piping Sump/Trench Sensor(s) Model: 0794380.208 Fill Sump Sensor(s) Model: 0794380-208 Fill Sump Sensor(s) Model: 0794380-208 ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: N Electronic Line Leak Detector Model: 0848480-001 0 Electronic Line Leak Detector Model: 0848480-001 ❑ 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: 132: DISPENSERS/UDC's Dispenser#: 112 Dispenser#: 314 E Dispenser Containment Sensoria) Model: 794390-460 E Dispenser Containment Sensor(s) Model: 794390480 Shear Valves E Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Floats)and Chains) Dispenser#: 5/6 Dispenser#: 718 N Dispenser Containment Sensors) Model: 794390460 N Dispenser Containment Sensoria) Model: 794390.480 Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) Dispenser#: 9/10 Dispenser#: 11/12 0 Dispenser Containment Sensors) Model: 794390.460 0 Dispenser Containment Sensors) Model: 794390-460 0 Shear Valves 0 Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) C. CERTIFICATION Icertify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines. Attached to this Certification is intormation(e.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing th 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 � y n 1WALTON Signature: i"'u�"r e' 1-r ENGINEERING,INC Septemper,19,2017 Technician/Carl M Robert Bush/A21523 Date: ©201 Walton Engineering,Inc.