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MONITO%WG SYSTEM CERTIFI*TION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: January 4, 2017 Al. FACILITY A2. OWNER Name Colonial Energy #40135 Name Colonial Energy, LLC. 192 Lathrop Road, Lathrop, CA 95330 Address 2860 N. Santiago Blvd. 2nd Floor, Orange, CA 92867 Address Phone# 209-858-4998 Phone# 714-761-5426 Contact Station Manager Contact Victor Hassan A4. TESTING CONTRACTOR A3. C U P A San Joaquin County Environmental Health Name Walton Engineering, Inc. Name 1868 E. Hazelton Avenue, Stockton, CA 95202 Address P.O. Box 1025, W. Sacramento, CA 95691 Address Notified December 21, 2016 Lic # 617238 A, B, Haz Inspector Garrett Backus 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) 61: TANKS — Tank#1 (Product): Gsaoline-87-1 Tank#2 (Product): Gasoline -87-2 —� ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: 0 Annular Space or Vault Sensor Model: 794390-060 E Annular Space or Vault Sensor Model: 794390.460 N Piping Sump / Trench Sensor(s) Model: 0794380-208 0 Piping Sump / Trench Sensor(s) Model: 0794380-208 0 Fill Sump Sensor(s) Model: 0794380-208 _ 0 Fill Sump Sensor(s) Model: 0794380-208_ _ ❑ Mechanical Line Leak Detector Model: _ ❑ Mechanical Line Leak Detector Model: _ Electronic Line Leak Detector Model: 0848480-001 ❑ Tank Overfill I High -Level Sensor Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill I High -Level Sensor Model: _ ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Madel: . Tank #3 (Product): Gasoline -91 Tank #4 (Product): Diesel ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe MotleC _ Annular Space or Vault Sensor Model: 794390.460 Annular Space or Vault Sensor Model: 794390-460 0 Piping Sump / Trench Sensor(s) Model: 0794380-208 Piping Sump I Trench Sensor(s) Model: 0794380-208 0 Fill Sump Sensor(s) Model: 0794380-208 ❑ Mechanical Line Leak Detector Model: Fill Sump Sensor(s) Model: 0794380-208 ❑ Mechanical Line Leak Detector Model: _ J Electronic Line Leak Detector Model: 0848480-001 _ Tank Overfill I High -Level Sensor Model: Electronic Line Leak Detector Model: 0848480-001 JI Tank Overfill / High -Level Sensor Model: _ E❑ ❑ Other equipment in Section E) Model: Other (specify equipment in Section E) Model: (specify — B2: DISPENSERSIUDC's �� Dispenser#: 1-2 Dispenser #: 3-4 0 Dispenser Containment Sensor(s) Model: 0794380-208 0 Dispenser Containment Sensor(s) Model: _0794380-208 M0 Shear Valves 0 Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) 7-8 Dispenser#: 5-6 Dispenser#: Dispenser Containment Sensor(s) Model: 0794380.208 0 Dispenser Containment Sensor(s) Model: 0794380-208 Shear Valves 0 Shear Valves ❑ Dispenser Containment Float(s) and Chains) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser #: 11-12 Dispenser #: 9-10 E Dispenser Containment Sensor(s) Model: 0794380-208 _ _ 0 Dispenser Containment Sensor(s) Model: 0794380-208 J Shear Valves 0 Shear Valves El Dispenser Containment Float(s) and Chain(s) _ _j ❑ 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 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 WALTON ------ Signature: Aj1-.., l�4�e"�'l�- ENGINEERING - INC. January 4, 2017 Technician I Cert #: Anthony Reyes 845115 8293772 Date: 0201'/ Walton Engineering, Inc.