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, MONITORING SYSTEM CERTIFICATI1 MAKE/ MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 Q F° `r 2 017 CERTIFICATION /TEST DATE: Se tember 20, 2017 Al. FACILITY A2. OWNER Name Teichert Mobile Equipment Name Teichert Construction �g . Address 120 Frank Circle,Stockton,CA 95206 Address P.O.Box 15002,Sacramento,CA 95851` 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 September 06,2017 Lic# 617238 A,B,Haz Inspector Ceasar 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): C1-Diesel Tank#2 (Product): C2-Gasoline-87 ❑ In-Tank Gauging Probe Model: 0 In-Tank Gauging Probe Model: 0847390-109 • Annular Space or Vault Sensor Model: 0794390-409 E Annular Space or Vault Sensor Model: 0794390-409 ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 N 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: N Electronic Line Leak Detector Model: 0848480-001 0 Electronic Line Leak Detector Model: 0848480-001 ❑ Tank Overfill/High-Level Sensor Model: N 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 • In-Tank Gauging Probe Model: 0847390-107 ❑ In-Tank Gauging Probe Model: • Annular Space or Vault Sensor Model: 0794390-009 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: 0847390-107 ❑ Tank Overfill I High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: B2: DISPENSERS/UDC's Dispenser#: 1-2 Dispenser#: 3-4 M 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,1 have also attached a copy of the report; (check all that apply ■ System set-up ■ Alarm History Report _ WALTON Signature: ENGINEERING,INC. Technician/Cert M Curtis Carpenter/B37268 8020679 Date: September 20, 2017 ©2017 Walton Engineering,Inc.