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<br /> WIONITWING SYSTEM CERTIWATION
<br /> MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350
<br /> CERTIFICATION /TEST DATE: December 16, 2008
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<br /> A1. FACILITY W A2. OWNER
<br /> Name Bonfare Market#35 Name Bonfare Markets,Inc.
<br /> < Address 15 W.Grant Line Road,Tracy,CA 95376 Address 461 S.Milpitas Blvd.,Suite 1,Milpitas,CA 95035
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<br /> Phone# 209-833-9619 Phone# 408-933-4422
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<br /> Contact Danny Arcayena Contact Sean Kapoor
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<br /> u A3. C U P A A4. TESTING CONTRACTOR
<br /> Name San Joaquin County Environmental Health Name Walton Engineering, Inc.
<br /> Address 600 E.Main Street,Stockton,CA 95202 Address P.O.Box 1025,W.Sacramento,CA 95691
<br /> Notified December 9,2008 Lic# 617238 A,B,Haz
<br /> Inspector Michelle Henry Contact Richard Walton
<br /> Phone# 209-468-3439 Phone# 916-825-3203
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<br /> B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to Indicate equipment Inspectediserviced)
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<br /> B1 TANKS
<br /> Tank#1 (Product): Gasoline-91 Tank#2 (Product): Gasoline-87 1 Y
<br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model:
<br /> ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Annular Space or Vault Sensor Model: 0794390-420
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<br /> ■ Piping Sump I Trench Sensor(s) Model: 0794380-208 ■ Piping Sump I Trench Sensor(s) Model: 0794380-208
<br /> ■ Fill Sump Sensor(s) Model: 0794380-208 ■ Fill Sump Sensor(s) Model: 0794380-208
<br /> ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model:
<br /> c ■ Electronic Line Leak Detector Model: 0848480-001 ❑ Electronic Line Leak Detector Model:
<br /> t ❑ Tank Overfill/High-Level Sensor Model: ? ❑ Tank Overfill/High-Level Sensor Model:
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<br /> kOther (specify equipment ment m Section E) Model:
<br /> ❑ Other (specify equipment in Section E) Model
<br /> Tank#3 (Product): Gasoline-87 2 Tank#4 (Product):
<br /> ❑ In-Tank Gauging Probe Model: In-Tank Gauging Probe Model:
<br /> y ■ Annular Space or Vault Sensor Model: 0794390-420 ❑ Annular Space or Vault Sensor Model:
<br /> » ■ Piping Sump I Trench Sensor(s) Model: 0794380-208 ❑ Piping Sump I Trench Sensor(s) Model
<br /> "; ■ Fill Sump Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model:
<br /> ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model:
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<br /> ■ Electronic Line Leak Detector Model: 0848480-001 ❑ Electronic Line Leak Detector Model:
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<br /> ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill(High-Level Sensor Model: sW
<br /> (specify ) P(specify )
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<br /> ❑ Otherequipment m Section E Model ❑ Other (s ecl equipment m Section E Model '
<br /> 1312 DISPENSERS/UDC's
<br /> ^, Dispenser#. 1-2 Dispenser#: 3-4 � '
<br /> ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Dispenser Containment Sensor(s) Model: 0794380-208
<br /> ■ Shear Valves ■ Shear Valves
<br /> ❑ Dispenser Containment Float(s)and Chain(s) El Dispenser Containment Float(s)and Chain(s)
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<br /> Dispenser#. 5-6 Dispenser#
<br /> ■ Dispenser Containment Sensor(s) Model: 0794380-208 ❑ Dispenser Containment Sensor(s) Model:
<br /> j. ■ Shear Valves ❑ Shear Valves
<br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chains)
<br /> Dispenser#: Dispenser#: N
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<br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model:
<br /> �? ❑ Shear Valves ! ❑ Shear Valves �
<br /> ❑ Dispenser Containment Float(s)and Cham(s) ❑ Dispenser Containment Float(s)and Chain(s)
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<br /> C. CERTIFICATION I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines.
<br /> Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing the
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<br /> 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):
<br /> ■ System set-up ■ Alarm History Report
<br /> ALTON 4
<br /> Signature: ENGINEERING,INC.
<br /> Technician 1 Cert M Bruce N.Stewart I A31131 5249892-UT Date: December X6,2008
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<br /> 2006 Walton Engineering,
<br /> Inc.
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