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416 2" 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-945 <br />Date of Test :7/15/20 Time: <br />Site Name: WEST LANE FUEL <br />Was power removed from the TLS -350 console? <br />Site Address: 3300 WEST LANE <br />19 <br />City: STOCKTON CA <br />Zip: 95204 <br />Technician: ED STEARNS <br />Veeder-Root: A31048 <br />District: SJVAPCD <br />VST: 3000967424 <br />SITE SHUTDOWN TESTI <br />est Parameter <br />Test Result (Y/N) <br />Was power removed from the TLS -350 console? <br />Y <br />Was power to the submersible pump(s) removed by the TLS -350? <br />Y <br />Was power restored to TLS -350 console? <br />Y <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 after reasonable inquiry, the statements and <br />information provided in this document are true, accurate, and complete. <br />i� <br />Signature of Technician: Date: 7/15/20 <br />Ver. 1.0 — 09.18.08 <br />