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MONITORING SYSTEM CERTIFICAT UE / MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root T S �► �/ CERTIFICATION / TEST DATE: January 03, 2018 0 RA A1. FACILITY A2. OWNER Name Colonial Energy#40135 Name Colonial Energy,LLC�.u�'3 nIt��II��I�TTppII u�I��©© Address 192 Lathrop Road,Lathrop,CA 95330 Address 2860 N.Santiago B, "TP 92887 Phone# 209-858-4998 Phone# 714-761-5426 DEPARTMENT 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# 209-468-3442 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipmentmspected/serviced) 1311: TANKS 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: 0794390420 ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ■ Fill Sump Sensor(s) Model: 0794380-208 ■ Fill 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 Madel: ❑ Tank Overfill I 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: 0794390-420 ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ■ Fill Sump Sensoria) Model: 0794380-208 ■ Fill 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 Sensor(s) Model: 0794380-208 ■ Dispenser Containment Sensors) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ 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 Chains) ❑ Dispenser Containment Hurtle)and Chain(s) Dispenser#: 9-10 Dis7D.pens#er 11-12 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Containment Sensor(s) Model: 0794380-208 ■ ShearValves ■ es ❑ Dispenser Containment Float(s)and Chains) ❑ 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 �,, ,,,�{. (�. n,,, po■ System set-up ■ Alarm History Report Signature: _ IH0 Technician/Cert#: Scott Beall/B451168319310 Date: ,Janualy3tZf, 2018 2017 Walton Engineering,Inc.