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MONITORING SYSTW CERTIFICATION - flage 1 Continuation <br /> MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 <br /> CERTIFICATION /TEST DATE: June 8, 2009 <br /> Al. FACILITY A2. OWNER <br /> Name New West#1003 Name New West Stations <br /> Address 6437 W. Banner Road, Lodi, CA 95242 Address 1831 16th Street,Sacramento, CA 95814 <br /> Phone# 916-443-0890 Phone# 916-443-0890 <br /> Contact Marta Garcia contact Marta Garcia <br /> B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) <br /> Bi (Continued): TANKS <br /> Tank#5 (Product): Tank#6 (Product): <br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: <br /> ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: <br /> ❑ Piping Sump/Trench Sensor(s) Model: ❑ Piping Sump/Trench Sensor(s) Model: <br /> ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: <br /> ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: <br /> ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: <br /> ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: <br /> ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: <br /> Tank#7 (Product): Tank#8 (Product): _ <br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: <br /> ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: <br /> ❑ Piping Sump/Trench Sensor(s) Model: ❑ Piping Sump/Trench Sensor(s) Model: <br /> ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: <br /> ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: <br /> ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: <br /> ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: <br /> ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: <br /> 132: (Continued) DISPENSERS/UDC's <br /> Dispenser#: 13-14 Dispenser#: 15-16 <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ■ Shear Valves ■ Shear Valves <br /> ■ Dispenser Containment Float(s)and Chain(s) ■ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: Dispenser#: <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: Dispenser#: <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: Dispenser#: <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: Dispenser#: <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: Dispenser#: <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> ©2006 Walton Engineering,Inc. <br /> Page la of 3 <br />