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MONITORING SYSTEM CERTIFICATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION / TEST DATE: January03, 2018 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 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 December 20,2017 Lic# 617238 A, B,Haz Inspector Betty Ho Contact Veronica Freitas Phone# 209468-3442 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TAMILS Tank#1 (Product): Gasoline 87-1 Tank#2 (Product): Gasoline 87-2. ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: Annular Space or Vault Sensor Model: 0794390.420 Annular Space or Vault Sensor Model: 0794390420 l� Piping Sump/Trench Sensors) Model: 0794380.208 Piping'Sump]Tranph lensor(s) Model: 0794380-208 Fill Sump Sensor(s) Model: 0794380.208 FII(Sump Sensors) Model:Model: 0794380.208 ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Madel: Electronic Line Leak Detector Model: 0848480-001 ❑ Electronic Line Leak DetectorModel: ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level SenszlT H 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: 0 Annular Space or Vault Sensor Model: 0794390420 Annular Space or Vault Sensor Model: 0794390420 0 Piping Sump/Trench Sensor(s) Model: 0794380-208 Piping Sump/Trench Sensoria) Model: 0794380-208 0 Fill Sump Sensor(s) Model: 0794380.208 Fill Sump Sensor(s) Model: 0794380.208 ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: Electronic Line Leak Detector Model: 0848980-001 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: 1312: DISPENSERS/UDC's Dispenser#: 1-2 Dispenser#: 3-4 ■ Dispenser Containment Sensor(s) Model: 0794380-208 N Dispenser Containment Sensor(s) Model: 0794380-208 M Shear Valves 0 Shear Valves ❑ Dispenser Containment Float(s)and Chains) ❑ Dispenser Containment Float(s)and Chains) Dispenser#: 5-6 Dispenser#: 7-8 Dispenser Containment Sensor(s) Model: _0794380-208 Dispenser Containment Sensor(s) Model: 0794380-208 Shear Valves Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Floats)and Chain(s) Dispenser#: 9-10 Dispenser#: 11-12 E Dispenser Containment Sensoria) Model: 0794380-208 0 Dispenser Containment Sensors) Model: 0794380-208 Shear Valves 0 Shear Valves ElDispenser Containment Float(s)and Chaln(s) ❑ 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 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 WONSignature: — � C.NGMEEe1Ne,INC. Technician/Cent M Scott Beall/8451168319310 Date: ,Jan uarv3rd 2018 0 2017 Walton Engineenng,Inc.