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MONIING SYSTEM CERTI ATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: October 28. 2013 A1. FACILITY Name Countryside 76 Address 14971 N. Highway 88, Lodi, CA 95240 Phone # 209-368-5380 Contact Rupinder Padda A2. OWNER Name Rupinder Padda Address 18662 North Hwy 88, Lockeford, CA 95237 Phone # 209-727-3064 Contact Rupinder Padda A3. C U P A INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) l31: TANKS A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Tank #1 (Product): Gasoline - 87 ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Address P.O. Box 1025, W. Sacramento, CA 95691 Notified October 23, 2013 Lic # 617238 A, B, Haz Inspector Aris Cacapit Model: Model: Model: Model: Model: Model: Model: Model: 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) l31: TANKS Tank #1 (Product): Gasoline - 87 ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Tank #2 (Product): Gasoline - 91 ❑ In -Tank Gauging Probe ❑ Annular Space or Vault Sensor ■ Piping Sump I Trench Sensor(s) ❑ 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: 0794380-208 Model: Model: Model: Model: Model: Tank #3 (Product): Diesel ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Tank #4 (Product): ❑ In -Tank Gauging Probe ❑ Annular Space or Vault Sensor ❑ Piping Sump I Trench Sensor(s) ❑ 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: Model: Model: Model: Model: Model: 62: DISPENSERS/UDC's 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) ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Model: 0794380-208 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 1 _ . \ f \� WALTON Signature: all O` W ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: October 28, 2013