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i T YT T T ■ I ■ ■ ■ IFI ■ I sp, MAKE/ MODEL OF MONITORING SYSTEM: Veeder-Root TLS-3d6 CERTIFICATION/TEST DATE: September 7, 2016 A1. FACILITY A2. OWNER _ Name Teichert Mobile Equipment Name Teichert Construction 5nM Address 120 Frank Circle,Stockton,CA 95206 Address P.O.Box 15002,Sacramento,CA`9S Phone# 916-366-8631 Phone# 916-386-3767 Contact Steve Schamaun Contact Steve Schamaun A3. C U P 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 August 24,2016 Lic# 617238 A,B,Haz Inspector Victoria McCartney Contact Veronica Freitas Phone# 209-468-3442 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS Tank#1 (Product): C-1 Diesel Tank#2 (Product): C-2 Gasoline-87 ❑ In-Tank Gauging Probe Model: 0 In-Tank Gauging Probe Model: 0847390-109 Annular Space or Vault Sensor Model: 0794390-409 0 Annular Space or Vault Sensor Model: 0794390-409 Piping Sump/Trench Sensor(s) Model: 0794380-208 0 Piping Sump/Trench Sensor(s) 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: 0848480-001 Electronic Line Leak Detector Model: 0848480-001 ❑ Tank Overfill/High-Level Sensor Model: Tank Overfill/High-Level Sensor Model: 0847390-109 ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank#3 (Product): WO-7 Used Waste Oil Tank#4 (Product): Lube 30-30 Oil In-Tank Gauging Probe Model: 0847390-107 ❑ In-Tank Gauging Probe Model: Annular Space or Vault Sensor Model: 0794390-409 Annular Space or Vault Sensor Model: 0794390-420 Piping Sump/Trench Sensor(s) Model: 0794380-208 ❑ 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: 0847390-107 ❑ 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# 1-2 Dispenser#: 3-4 Dispenser Containment Sensor(s) Model: 0794380-208 Dispenser Containment Sensor(s) Model: 0794380-208 Shear Valves Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) Dispenser#: Dispenser# ❑ 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#: Dispenser# ❑ 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) 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 th 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 0 Alarm History Report LTON Signature: ._,. ENGINEERING,INC. Technician/Cert#: Curtis Carpenter/B37268 8020679 Date: September 7,2016 ©2016 Walton Engineering,Inc.