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MONITORING SYSTEM CERTIFICATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION /TEST DATE: January 5, 2016 A1. FACILITY A2. OWNER 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 A4. TESTING CONT T r Name San Joaquin County Environmental Health Name Walton E(1 ni Address 1868 E-Hazelton Avenue,Stockton,CA 95202 Address P.O. Box 1026,:W.. crai a to,b" Notified December 23,2015 Lic# 617238 A, B,Haz Inspector Victoria McCartney Contact Veronica Freitas Phone# 209-468-8257 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to tnpicate equipment inspected/serviced) B1: TANKS k ff -- Tank#1 (Product): Gsaoline-87-1 Tank#2 (Product): Saso ine-87-2 ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390420 ■ Annular Space or Vault Sensor Model: 0794390320 ■ Piping Sump/Trench Sensoria) Model: 0794380-208 ■ Piping Sump/Trench Sensoria) Model: 0794380.208 ■ FIII Sump Sensors) Model: 0794380.208 ■ FIII 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: ❑ 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: 0794390420 ■ Annular Space or Vault Sensor Model: 0794390320 ■ Piping Sump/Trench Sensoria) Model: 0794380-208 _ ■ Piping Sump/Trench Sensoria) Model: 0794380-208 ■ FIII Sump Sensoria) Model: 0794380-208 ■ FIII Sump Sensoria) 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: 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: B2: DISPENSERS/UDC's Dispenser#: 1-2 Dispenser#: 3-4 ■ Dispenser Containment Sensoria) Model: 0794380-208 ■ Dispenser Containment Sensoria) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Floats)and Chain(s) ❑ Dispenser Containment Float(s)and Chaln(s) Dispenser#: 5.6 Dispenser#: 7-8 ■ Dispenser Containment Sensoria) Model: 0794380-208 ■ Dispenser Containment Sensoria) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s)and Chaln(s) ❑ Dispenser Containment Float(s)and Chain(s) Dispenser#: 9-10 Dispenser#: 11-12 ■ Dispenser Containment Sensors) Model: 0794380-208 ■ Dispenser Containment Sensorial Model: 0794380.208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Cham(s) C. CERTIFICATION I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines. Attached to this Certificadon is information(e.g.manufacturerschecklists)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 ,,,,'' WON Signature: //r�"('�� ENGINEERING,INC. Technician/Cart M Thomas Steiger A31060/8156310 Date: Jan Dairy 5, 2016 02015 Walton Engineering,Inc.