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MONITCVING SYSTEM CERTIFWATION MAKE / MODEL OF MONITORING SYSTEM: CERTIFICATION /TEST DATE: December 10, 2010 Al. FACILITY Name Olympian # 427 Address 3300 Waterloo Road, Stockton, CA 95205 Phone # 530-885-0401 Contact Amanda Appelt A2. OWNER Name Nella Oil Company, LLC Address 2360 Lindbergh Street, Auburn, CA 95602 Phone # 530-885-0401 Contact Amanda Appelt Address 600 E. Main Street, Stockton, CA 95202 A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #1 (Product): Name Walton Engineering, Inc. Address 600 E. Main Street, Stockton, CA 95202 In -Tank Gauging Probe Address P.O. Box 1025, W. Sacramento, CA 95691 Notified December 8, 2010 ❑ Lic # 617238 A, B, Haz Inspector Jeff Wong Model: 0794390-420 Contact Dulcinea Covan Phone # 209-468-8257 Piping Sump / Trench Sensor(s) Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) 131- TANKS =moi �] 6y, � ► 69 �:�•'ilU aZ� Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ❑ ❑ ❑ Tank #1 (Product): Tank #2 (Product): Gasoline - 87 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ■ Annular Space or Vault Sensor Model: 0794390-420 ❑ Piping Sump / Trench Sensor(s) Model: ❑ Piping Sump / Trench Sensor(s) Model: ❑ 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 / 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): Red Diesel 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 I Trench Sensor(s) Model: ❑ Piping Sump / Trench Sensor(s) Model: ❑ 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 / High -Level Sensor Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: =moi �] 6y, � ► 69 �:�•'ilU aZ� 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 History Report WALTON Signature: ' 7 A / �4 ENGINEERING, INC. Technician / Cert M Ryan Powell 833011 / 5257345 -UT Date: December 10, 2010 Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ❑ ❑ ❑ # : Dispenser Containment Sensor(s) Model: Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ❑ ❑ ❑ # : Dispenser Containment Sensor(s) Model: Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ 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 History Report WALTON Signature: ' 7 A / �4 ENGINEERING, INC. Technician / Cert M Ryan Powell 833011 / 5257345 -UT Date: December 10, 2010