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I MONITORING SYSTEM CERTIFICATION JAN 13 2017 I MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION / TEST DATE: January 4, 20171=NVIR0NMFNTA1 HFALTH Al. FACILITYA2. OWNER A Name Colonial Energy #40135 Name Colonial Energy, LLC. Address 192 Lathrop Road, Lathrop, CA 95330 Address 2860 N. Santiago Blvd. 2nd Floor, Orange, CA 92867 Phone # 209-858-4998 Phone # 714-761-5426 Contact Station Manager Contact Victor Hassan A3. C U P A Dispenser # : 3-4 A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank#2 (Product): Gasoline -87-2 Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Address P.O. Box 1025, W. Sacramento, CA 95691 Notified December 21, 2016 Lie # 617238 A, B, Haz Inspector Garrett Backus Annular Space or Vault Sensor Contact Veronica Freitas Phone# 209-468-3442 Model: Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS Tank#1 (Product): Gsaoline-87-1 Dispenser # : 3-4 0 Dispenser Containment Sensor(s) Model: 0794380-208 Tank#2 (Product): Gasoline -87-2 Model: 0794380-208 '. ❑ In -Tank Gauging Probe Model .; ❑ In -Tank Gauging Probe Model: Chain(s) Annular Space or Vault Sensor Model: 794390-460 Dispenser # : 5-6 Annular Space or Vault Sensor Model: 794390-460 Model: 0794380.208 Piping Sump/ Trench Sensors) Model: 0794380.208 Piping Sump f Trench Sensors) Model: 0794380-208 Chain(s) Fill Sump Sensors) Model 0794380-208 .:: Fill Sump Sensor(s) Model: 0794380.208 ❑ Mechanical Line Leak Detector Model: M Dispenser Containment Sensors) ❑ Mechanical Line Leak Detector Model: M Shear Valves Electronic Line Leak Detector Model: _ ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: _0.8_48480-001 ": ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank #4 (Product): Diesel Tank#3 (Product): Gasoline -91 ❑ 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 Sensoria) Model: 0794380.208 Piping Sump/ Trench Sensor(s) Model: 0794380-208 • Fill Sump Sensor(s) Model: 0794380-208 Fill Sump Sensors) Model: 0794380-208 ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: Electronic Line Leak Detector Model: 0848480-001 Electronic Line Leak Detector Model: 0849480-001 ❑ 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: E12: DISPENSERS/UDC's Dispenser # : 1-2 Dispenser # : 3-4 0 Dispenser Containment Sensor(s) Model: 0794380-208 0 Dispenser Containment Sensors) Model: 0794380-208 Shear Valves M Shear Valves ❑ Dispenser Containment Floats) and Chain(s) ❑ Dispenser Containment Floats) and Chain(s) Dispenser # : 7-8 Dispenser # : 5-6 M Dispenser Containment Sensor(s) Model: 0794380-208 M Dispenser Containment Sensors) Model: 0794380.208 M Shear Valves M Shear Valves ❑ Dispenser Containment Floats) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser#: 9-10 Dispenser#: 11-12 M Dispenser Containment Sensoria) Model: 0794380-208 M Dispenser Containment Sensors) Model: 079.4380-208 M Shear Valves M Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ 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 n WALTor Signature: A ��•Q�l--' �. NGINEENING, INC. Technician/Cert#: Anthony Reyes B45115 8293772 Date: Ja aary4,2017