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MONITWING SYSTEM CERTIF&ATION MAKE/ MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: March 5, 2014 Al. FACILITY A2. OWNER Name Tower Mart # 104 Name Tower Energy Group, Inc. Address 192 Lathrop Road, Lathrop, CA 95330 Address 1983 West 190th Street, Torrance, CA 90504 Phone# 209-858-4998 Phone# 916-285-7402 ext 100 Contact Desiz Burns Contact Mark Vasey A3. C UP 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 February 25, 2014 Lic # 617238 A, B, Haz Inspector Elena Manzo Contact Dulcinea Covan Phone# 209-468-8257 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to Indicate equipment inspected/serviced) B1: TANKS Tank #1 (Product): Gasoline - 87 M Tank #2 (Product): Gasoline -87S ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensors) Model: ❑ Piping Sump / Trench Sensoria) Model: ❑ Fill Sump Sensoria) Model: ❑ Fill Sump Sensor(s) Madel: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ''� ❑ Electronic Line Leak Detector Model: ❑ 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: 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: 1 ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensor(s) Model: ■ Piping Sump / Trench Sensoria) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill I High -Level Sensor Model: ❑ Tank Overfill I High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: B2: DISPENSERS/UDC's Dispenser # : Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensoria) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Floats) and Chain(s) Dispenser # : Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensoria) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : Dispenser # ❑ Dispenser Containment Sensors) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chafn(s) ❑ Dispenser 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 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): ■ System set-up ■ Alarm Histo Report ,, ^^ (0 %% I �/I �J/1 WALTON Signature: './' C(y�y,((/ NGINc EFING, MC. Technician I Cert #: Chris Kuykendall / B42243 8161927 Date: March 5, 2014