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MONIT(VING SYSTEM CERTIFOATION MAKE / MODEL OF MONITORING SYSTEM: Veeder Root TLS350 CERTIFICATION /TEST DATE: December 2. 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 A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 600 E. Main Street, Stockton, CA 95202 Address P.O. Box 1025, W. Sacramento, CA 95691 Notified November 18, 2010 Lic # 617238 A, B, Haz Inspector Jeff Wong 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) 131: TANKS 132: DISPENSERS/UDC's Dispenser # : 1 Dispenser # : 2 ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 3/4 Dispenser # : 5 ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 8 ❑ 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 / O WALTON .. Signature: a _ ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: December 2, 2010 Tank #1 (Product): Gasoline 87 Tank #2 (Product): Red 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 / Trench Sensor(s) Model: 0794380-208 ■ Piping Sump / Trench Sensor(s) Model: 0794380-205 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: FE Petro STP -MLD ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill I 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): Diesel Tank #4 (Product): _ ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-420 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) Model: 0794380-205 ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ 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: 132: DISPENSERS/UDC's Dispenser # : 1 Dispenser # : 2 ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 3/4 Dispenser # : 5 ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 8 ❑ 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 / O WALTON .. Signature: a _ ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: December 2, 2010