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MONITORING SYSIMM CERTIFICATION Page 1 Continuation <br />MAKE/ MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 <br />CERTIFICATION/ TEST DATE: January 7, 2015 1 <br />A1. FACILITY <br />A2. OWNER <br />Name Tower Mart # 104 <br />Name Tower Energy Group, Inc. <br />Address 192 Lathrop Road, Lathrop, CA 95330 <br />Address 1983 West 190th Street, Torrance, CA 90504 <br />Phone# 209-858-4998 <br />Phone# 916-285-7402 ext 100 <br />Contact Desiz Burns <br />Contact Mark Vasey <br />B. INVENTORY OF EQUIPMENT TESTEDICERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) <br />B1 (Continued): TANKS <br />) <br />_ <br />Tk #5 (Product) Tank #6 (Product): <br />— <br />❑ In Tank GaugingProbe Model: <br />❑ In -Tank Gauging Probe Model: <br />❑ Annular Space or Vault Sensor Motlel.____ ElAnnular Space or Vault Sensor Model: <br />El Piping Sump / Trench Sensor(s) Model: ❑ Piping Sump / Trench Sensors) Model: <br />❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensoria) Model: <br />- _ <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 I High -Level Sensor Model: ❑ Tank Overfill / High -Level Sensor Model: <br />-Other <br />'. El (specify equipment in Section E) Model j ❑ Other (specify equipment in Section E) Model: � <br />Tank #7 (Product): FTnk #8 (Product): <br />❑ In -Tank Gauging Probe Mod a]: ❑ In -Tank Gauging Probe Model: <br />❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: <br />❑ Piping Sump / Trench Sensoria) Model: ❑ Piping Sump I Trench Sensor(s) Model: <br />❑ Fill Sump Sensoria) Model: ❑ Fill Sump Sensoria) Model: <br />❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: <br />[_1 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 />B2: (Continued) DISPENSERS/UDC's <br />Dispenser #: 13-14 <br />Dispenser # : 15-16 <br />■ Dispenser Containment Sensoria) Model: 0794380-208 <br />penser Containment Sensoria) Model: 0794380.208 <br />■ Shear Valves <br />ear Valves <br />LODispenser <br />❑ Dispenser Containment Floats) and Chain(s) <br />Containment Float(s) and Chains) <br />- <br />Dispenser # : 17-18 <br />Dispenser # : 19-20 <br />■ Dispenser Containment Sensoria) Model: 0794380-208 <br />■ Dispenser Containment Sensoria) Model: 0794380-208 <br />■ Shear Valves <br />■ Shear Valves <br />❑ Dispenser Containment Floats) and Chain(s) - <br />❑ Dispenser Containment Float(s) and Chain(s) <br />Dispenser#: 21-22 <br />F—Dispenser#: 23-24 <br />■ Dispenser Containment Sensoria) Model: 0794380.208 <br />Dispenser Containment Sensoria) Model: 0794380.208 <br />■ Shear Valves <br />Shear Valves <br />LCON <br />❑ Dispenser Containment Floats) and Chain(s) <br />Dispenser Containment Float(s) and Chain(s) J <br />_. —_ __.. <br />Dispenser#:_. <br />Dispenser#: <br />❑ Dispenser Containment Sensors) Model: �; <br />❑ Dispenser Containment Sensor(s) Model: <br />❑ Shear Valves <br />❑Shear Valves <br />E3 Diapers er Containment Float(s) and Chain(s) <br />LEIDispenserContainment Float(s) and Chains) <br />Dispenser # : Dispenser # . <br />❑ Dispenser Containment Sensoria) Model: ❑ Dispenser Containment Sensoria) Model: <br />❑ Shear Valves ❑ Shear Valves <br />❑ Dispenser Containment Float(s) and Chains) ❑ Dispenser Containment Float(s) and Chain(s) <br />-� <br />Dispenser # : Dispenser # <br />F❑ <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 <br />" <br />-_ Float(s) and Chain(s) <br />Page la of 3 <br />