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fforda-Te t 416 2"1 Street <br /> Galt, CA 95632 <br /> (209) 744-0113 Fax (209) 744-0116 <br /> E.O.VR-204 <br /> Veeder-Root In-Station Diagnostics Site Shutdown Test Report Form <br /> Permit Number: N-9259 Date of Test: 12/6/2018 Time: <br /> Site Name: GRIN INVESTMENTS ARCO AMPM <br /> Site Address: 6009 N. EL DORADO STREET <br /> City: STOCKTON, CA Zip: 95207 Technician: ZANE NIMMO <br /> Veeder-Root: A 28446 <br /> District: SJVAPCD <br /> SITE SHUTDOWN TESTI <br /> Test Parameter Test Result(Y/N) <br /> Was power removed from the TLS-350 console? Yes <br /> Was power to the submersible pump(s)removed by the TLS-350? Yes <br /> Was power restored to TLS-350 console? Yes <br /> COMMENTS (Include Description of Repairs Made) <br /> NOTES: lA certified Veeder-Root technician must perform this test. <br /> I declare, under penalty of perjury under the laws of the state of California that based on information and belief formed <br /> after reasonable inquiry, the statements and information provided in this document are true, accurate, and complete. <br /> Signature of Technician: Date: 12/6/2018 <br /> Ver. 1.0—09.18.08 <br />