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.APAIM All <br />llorda�Te� I I M <br />416 2"Street <br />Galt, CA 95632 <br />(209) 744-0113 Fax (209) 744-0116 <br />E.O. VR -204 <br />Veeder-Root In -Station Diagnostics Site Shutdown Test Report Form <br />Permit Number: N472144 <br />CONF # l&25877 <br />Date of Test: 9/6/2018 Time, <br />Site Name: FOOD <br />MART GAS <br />Was power to the submersible pump(s) removed by the TLS -350? <br />Yes <br />Was power restored to TLS -350 console? <br />Yes <br />Site Address: 2185 <br />E. FREMONT STREET <br />_ <br />City: STOCKTON <br />Zip: 95205 <br />Technician: ZANE NIMMO <br />Veeder-Root: A28446 SEP <br />District: S J V A P <br />C D <br />ENVIRONMENIAL <br />r A <br />SITE SHUTDOWN TESTI <br />Test Parameter <br />Test Result (Y/1) <br />Was power removed from the TLS -350 console? <br />Yes <br />Was power to the submersible pump(s) removed by the TLS -350? <br />Yes <br />Was power restored to TLS -350 console? <br />Yes <br />COMMENTS (Include Description of Repairs Made) <br />NOTES: 'A certified Veeder-Root technician must perform this test. <br />JT <br />I declare, under penalty of perjury under the laws of the state of California that based on information and belief formed <br />after reasonable inquiry, thes tements and information provided in this document are if accurate, and complete. <br />Signature of Technician: . <br />Date: 9/6/2018 <br />Ver. I.0 — 09. l 8.08 <br />