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MONIT&ING SYSTEM CERTI` #ATION MAKE / MODEL OF MONITORING SYSTEM: Gilbarco EMC CERTIFICATION /TEST DATE: June 8, 2012 A1. FACILITY A2. OWNER Name Tracy 76 - Reliance Gas Investments, Inc. Name Jivtesh Gill Address 2420 W. Grantline Road, Tracy, CA 95337 Address 4855 South State Hwy 99, Stockton, CA 95215 Phone# Phone# 209-948-2438 Contact Jivtesh Gill Contact Jivtesh Gill 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 PRETEST Lic # 617238 A, B, Haz Inspector None 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) 61: TANKS Tank #1 (Product): Gasoline - 87 Tank #2 (Product): Gasoline - 91 ■ In-Tank Gauging Probe Model: PA02650900200 ■ In-Tank Gauging Probe Model: PA02650960200 ■ Annular Space or Vault Sensor Model: 794390-420 ■ Annular Space or Vault Sensor Model: 794390-420 ■ Piping Sump / Trench Sensor(s) Model: 0794360-205 ■ Piping Sump / Trench Sensor(s) Model: 0794380-205 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) 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 / High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment In Section E) Model: Tank #3 (Product): Diesel Tank #4 (Product): ■ In-Tank Gauging Probe Model: PA02650960200 ❑ In-Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) Model: 0794380-205 ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) 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 / High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment In Section E) Model: B2: DISPENSERS/UDC's Dispenser # : Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chaln(s) ❑ Dispenser Containment Float(s) and Chaln(s) Dispenser # FDispenser # - ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chaln(s) ❑ Dispenser Containment Float(s) and Chaln(s) Dispenser # : Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chaln(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, I have also attached a copy of the report: (check all that apply): ■ System set-up ■ Alarm History Report WALTON Signature: ENGINEERING, INC. Technician / Cert #: Steve Flores B36194 /5252243-UI Date: June 8, 2012