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MONITCWING SYSTEM CERTIFfATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: March 29, 2010 Al. FACILITY A2. OWNER Name CRLLC #2705446 Name Pacific Convenience and Fuels, LLC Address 1403 Country Club Blvd., Stockton, CA 95204 Address 2603 Camino Ramon, Ste 350, San Ramon, CA 94583 Phone # 209-943-2082 Phone # 925-884-0827 Contact Belinda Sawyer Contact Compliance Officer A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #1 (Product): Diesel 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 March 23, 2010 ❑ Lic # 617238 A, B, Haz Inspector Garrett Backus Model: Contact Richard Walton Phone # 209-468-3439 Piping Sump / Trench Sensor(s) Phone # 916-825-3203 Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) Model: 131: TANKS Model: VMI 99LD-2000 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) ❑ Shear Valves ❑ Dispenser Containment Float(s) and Model: 132: DISPENSE RS/UDC's Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) ❑ Shear Valves Model: ❑ Dispenser Containment Float(s) and Chain Dispenser # : ❑ Dispenser Containment Sensor(s) ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain Model: 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): ■ Svstem set-up ❑ Alarm History Report I \ Q WALTON Signature: W aJ �_ ENGINEERING, INC. Technician I Cert #: Jessie Wadkins / B36391 5307886 -UT Date: March 29, 2010 Tank #1 (Product): Diesel 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: ❑ 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: VMI 99LD-2000 ❑ 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: Tank #3 (Product): Gasoline 91 Tank #4 (Product): ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ 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: 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) ❑ Shear Valves ❑ Dispenser Containment Float(s) and Model: 132: DISPENSE RS/UDC's Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) ❑ Shear Valves Model: ❑ Dispenser Containment Float(s) and Chain Dispenser # : ❑ Dispenser Containment Sensor(s) ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain Model: 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): ■ Svstem set-up ❑ Alarm History Report I \ Q WALTON Signature: W aJ �_ ENGINEERING, INC. Technician I Cert #: Jessie Wadkins / B36391 5307886 -UT Date: March 29, 2010