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MONIT(_IING SYSTEM CERTh ,_ZATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION /TEST DATE: March 3, 2011 A7. FACILITY A2. OWNER Name Circle K#2701205 Name Circle K Stores, Inc. Address 16470 Cambridge, Lathrop,CA 95330 Address 255 E Rincon Street,Suite 100,Corona,CA 92879 Phone# 209-858-4116 Phone# 951-270-5183 Contact Rex Abacan Contact Rex Abacan A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 600 E. Main Street,Stockton,CA 95202 Address P.O.Box 1025,W.Sacramento,CA 95691 Notified March 2,2011 Lic# 617238 A,B, Haz Inspector Thuy Tran Contact Dulcinea Coven Phone# 209-468-8257 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) 81: TANKS Tank#1 (Product): Gasoline-87 Tank#2 (Product): ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensors) Model: ❑ Piping Sump/Trench Sensor(s) Model: ❑ Fill Sump Sensors) Model: ❑ Fill Sump Sensoria) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank#3 (Product): Tank#4 (Product): ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump/Trench Sensors) Model: ❑ Piping Sump/Trench Sensoria) Model: ❑ Fill Sump Sensoria) Model: ❑ Fill Sump Sensoria) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill I High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment In Section E) Model: B2: DISPENSERS/UDC's Dispenser#: Dispenser 9: ❑ Dispenser Containment Sensoria) Model: ❑ Dispenser Containment Sensors) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Floatfs)and Chain(s) Dispenser#: Dispenser#: ❑ Dispenser Containment Sensors) Model: ❑ Dispenser Containment Sensors) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Floats)and Chain(s) ❑ Dispenser Containment Floatfs)and Chain(s) Dispenser#: Dispenser#: ElDispenser Containment Sensors) Model: ElDispenser Containment Sensorfs) Model: ElShear Valves ElShear Valves ❑ Dispenser Containment Float(s)and Cham(s) ❑ 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,1 have also attached a copy of the report; (check all that apply): ❑ System set-up ❑ Alarm History Report WALTON Signature: c< ENGINEERING.INC, Technician/Cert M Curtis Carpenter 1837258 8020679 Date: March 3, 2011 02011 Walton Engme,mng,Inc.