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MONITC#ING SYSTEM CERT1F4fAT10Prj MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: September 11, 2015 SEP 21 2015 A1. FACILITY Name Teichert Mobile Equipment Address 120 Frank Circle, Stockton, CA 95206 Phone # 916-366-8631 Contact Steve Schamaun A2. OWNER ENVIRONMENTAL Name Teichert Construction I -jcp1TU r)CODpTAAChiT Address P.O. Box 15002, Sacramento, CA 95851 Phone # 916-386-3767 Contact Steve Schamaun A3. C U P A Dispenser # : North Disp ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Tank #2 (Product): C-2 Gasoline - Address P.O. Box 1025, W. Sacramento, CA 95691 Notified August 28, 2015 Model: Lic # 617238 A, B, Haz Inspector Stacy Rivera 0847390-109 Contact Veronica Freitas Phone # 209-468-8257 ■ Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to Indicate equipment inspected/serviced) B1 _ TANKS t32' OISPFNSFR3/llf]C'ee Dispenser # : North Disp ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : South Disp ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ 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) Tank #1 (Product): CA Diesel Tank #2 (Product): C-2 Gasoline - 87 ❑ In -Tank Gauging Probe Model: ■ In -Tank Gauging Probe Model: 0847390-109 ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ■ 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: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): WO -7 Used 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: ❑ Piping Sump / Trench Sensor(s) Model: ■ Fill Sump Sensor(s) Model: 0794380-208 ❑ 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: t32' OISPFNSFR3/llf]C'ee 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: ENGINEERING, INC. Technician / Cert #: Curtis Carpenter/ B37258 8020679 Date: September 11, m5 Dispenser # : North Disp ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : South Disp ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ 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: ENGINEERING, INC. Technician / Cert #: Curtis Carpenter/ B37258 8020679 Date: September 11, m5