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MONITORING SYSTEM CERTIFICATION - Page 1 Continuation <br /> MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 <br /> CERTIFICATION / TEST DATE: January03, 2018 <br /> Al. FACILITY A2. OWNER <br /> Name Colonial Energy#40135 Name Colonial Energy, LLC. <br /> Address 192 Lathrop Road, Lathrop,CA 95330 Address 2860 N.Santiago Blvd. 2nd Floor,Orange,CA 928E <br /> Phone# 209-858-4998 Phone# 714-761-5426 <br /> Contact Station Manager Contact Victor Hassan <br /> B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) <br /> B1 (Continued): TANKS <br /> Tank#5 (Product): Tank#6 (Product): <br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: <br /> ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: <br /> ❑ Piping Sump/Trench Sensots) Model: ❑ Piping Sump/Trench Sensor(s) Model: <br /> ❑ FIII Sump Sensots) Model: ❑ Fill Sump Sensoria) Model: <br /> ❑ Mechanical Line Leak Detector Model: _ _ _ ❑ Mechanical Line Leak Detector Model: <br /> ❑ Electronic Line Leak Detector Model: ❑"'Electronic Line Leak Detector Model: <br /> ❑ Tank Overfill f High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: <br /> ❑ Other (specify equipment in Section E) Model: ❑ Other(specify equipment in Section E) Model: <br /> Tank#7 (Product): Tank#8 (Product): <br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: <br /> ❑ Annular Space or Vault Sensor ModsC/ _ ❑ Annular Space or Vault Sensor Model: <br /> tii, <br /> ❑ Piping Sump/Trench Sensor(s) Model DER <br /> _ _[)., [PIFI?Sump f Trench Sensots) Model: <br /> ❑ Fill Sump Sensoria) Model: �Cf-'r„ ; ❑ FIII Sump Sensor(s) Model: <br /> ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: <br /> ❑ Electronic Line Leak Detector Model:_ _ ❑ Electronic Line Leak Detector Model: <br /> ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: <br /> ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: <br /> 82: (Continued) DISPENSERS/UDC's <br /> Dispenser#: 13-14 Dispenser#: 15-16 <br /> Dispenser Containment Sensoria) Model: 0794380-208 Dispenser Containment Sensors) Model: 0794380-208 <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chains) ❑ Dispenser Containment Float(s)and Chains) <br /> Dispenser#: 17-18 Dispense #: 19-20 <br /> E Dispenser Containment Sensoria) Model: 0794380-208 0 Dispenser Containment Sensoria) Model: 0794380-208 <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chains) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: 21-22 —� Dispenser#: 23-24 <br /> E Dispenser Containment Sensor(s) Model: 0794380-208 N Dispenser Containment Sensor(s) Model: 0794380-208 <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: LD,,ilpenser# <br /> ElDispenser Containment Sensor(s) Model: Dispenser Containment Sensor(s) Motlel: <br /> E] ShearValves Shear Valves <br /> ElDispenser Containment Floats)and Chain(s) Dispenser Containment Floats)and Chaln(s) <br /> Dispenser#: Dispenser#: <br /> ❑ Dispenser Containment Sensors) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Floats)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: Dispenser#: <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> ®2017 Welton Engineering,Inc. <br />