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MONIT . ING SYSTEM CERTI r..ATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 JAN 21 2014 CERTIFICATION /TEST DATE: Januiaryl4,2014 A1. FACILITY Name A2. OWNER NTAt HL:fti- Tower Mart # 104 ^ ' Name Tower Energy Group, Inc. `RMI71SERVIC,a- Address 192 Lathrop Road, Lathrop, CA 95330 Phone # 209-8584998 Address 1983 West 190th Street, Torrance, CA 90504 Contact Desiz Bums Phone # 916-285-7402 ext 100 Contact Mark Vasey A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Name Walton Engineering, Inc. Notified January 7, 2014 Address P.O. Box 1025, W. Sacramento, CA 95691 Lic # 617238 A, B, Haz Inspector Jeff Wong Contact Dulcinea Coven Phone # 209468-8257 Phone # 916-373-1166 B. INVENTORY OF EQUIPMENTTESTED/CERTIFIED (Check the appropriate boxes to Indicate equipment inspected/serviced) _ B1: TANKS -- rTank Tank #2 (Product): Gasoline87-2 - #1 (Product): Gasoline - 87-1 ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: or ■ Annular Space or Vault Sensor Model: 0794390420 ■ Annular Space or Vault Sensor Model: 0784390420 ■ Piping Sump / Sensor(s) Model: _0784380.208 ■ Piping Sump / Trench Sensor(s) Model: 0794380.208 ■ Fill Sump Sensoria) Model: 0794380.208 ■ Fill Sump Sensor(s) Model: 0784380.208 ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ■ Electronic Line Leak Detector Model: 0848480-001 Line Leak Detector MotleModel;ElTank Overfill / High-Level Sensor Model: El Tank Tank Over ill / High-Level Sensor Model: El Other (specify equipment in Section E) Motlel: L Other (specify equipment in Section E) Model: _ _� Tank #3 (Product): Gasoline .9i _ Tank #4 (Product): Diesel ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Motlel ■ Anular Space or Vault Sensor Model: 0794390420 _ ■ Piping Sump /Trench Sensorial Model: 0794380.208 ■ Annular Space or Vault Sensor Model' 0784390420 ■ Piping Sump / Trench Sensoria) Motlel: 0794380.208 ■ Fill Sump Sensor(s) Model: 0794380.208 ■ Fill Sump Sensor(s) Model: 0784980-208 ❑ Mechanical Line Leak Detector Model: ❑Mechanical Line Leak Detector Model: ■ Electronic Line Leak Detector Model: 0849480-M ■ 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: 0784380.208 ■ Dispenser Containment Sensor(s) Model: 0794380.208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chains) ❑ Dispenser Containment Floats) and Chain(s) Dispenser # : 5-6 Dispenser # : 7-$ ■ Dispenser Containment Sensorial Model: 0784380.208 ■ Dispenser Containment Sensors) Model: 0794380.208 ■ Shear Valves ■ Shear Valves I ❑ Dispenser Containment Float(s) � P _ and Chain(s) _._- .. _ ❑ Dispenser Containment Float(s) and Chains) - Dispenser#: 9-10 Dispenser#: 11-12 -- ■ Dispenser Containment Sensor(s) Model: 0784380.208. ■ Dispenser Containment Sensor(a) Model: 0794380.208 ■ Shear Valves ■ 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 inspected1serviced In accordance with the manufacturers' Attached guidelines. to this Certification Is information (e.g. manufactures' checklists) necessary to verify that this Information is correct Plot and a Plan showing the 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): ■ S stem set-up ■ Alarm History Report 11 ` pp/p I �,.��eP_ WALTON fl�l 9 _ Signature: JJ 1 Technician / Cert#: Jessie Wadkins / B35391 5307886-UT Date: January 14, 2014 w avta Walton Engineering, Inc.