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MONIT fFING SYSTEM CERTISCATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION / TEST DATE: September 13. 2012 Al. FACILITY Name Teichert Mobile Equipment Address 120 Frank Circle, Stockton, CA 95206 Phone # 916-366-8631 Contact Steve Schamaun A2. OWNER Name Teichert Construction Address P.O. Box 15002, Sacramento, CA 95851 Phone # 916-386-3767 Contact Steve Schamaun A3. C U P A Tank #2 (Product): Gasoline - 87 ■ A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health In -Tank Gauging Probe Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 ■ Address P.O. Box 1025, W. Sacramento, CA 95691 Notified September 5, 2012 Model: 0794380-208 Lie # 617238 A, B, Haz Inspector Stacy Rivera Fill Sump Sensor(s) Mechanical Line Leak Detector Electronic Line Leak Detector Tank Overfill / High -Level Sensor Other (specify equipment in Section E) 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) B1' TANKS Tank #1 (Product): Diesel 1 Tank #2 (Product): Gasoline - 87 ■ In -Tank Gauging Probe Model: 0847390-109 ■ 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) Mechanical Line Leak Detector Electronic Line Leak Detector Tank Overfill / High -Level Sensor Other (specify equipment in Section E) Model: Model: Model: 0848480-001 Model: Model: ❑ ❑ ■ ■ ❑ Fill Sump Sensor(s) Mechanical Line Leak Detector Electronic Line Leak Detector Tank Overfill / High -Level Sensor Other (specify equipment in Section E) Model: Model: Model: 0848480-001 Model: 0847390-109 Model: Tank #3 (Product): Waste oil Tank #4 (Product): Diesel 2 ■ 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: ❑ Piping Sump / Trench Sensor(s) Model: ■ Piping Sump I Trench Sensor(s) Model: 0794380-208 ■ 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: 0848480-001 ■ 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' UISPFNSFRSill inu n 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 LCL �:E WALTON Signature: ENGINEERING, INC. Technician / Cert #: Curtis Carpenter / B37258 8020679 Date: September 13, 2012 Dispenser # : 1-2 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ■ ■ ❑ # : 3-4 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 LCL �:E WALTON Signature: ENGINEERING, INC. Technician / Cert #: Curtis Carpenter / B37258 8020679 Date: September 13, 2012