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MONITGVING SYSTEM CERTIFOATION MAKE / MODEL OF MONITORING SYSTEM: CERTIFICATION /TEST DATE: May 20, 2010 A1. FACILITY A2. OWNER Name CRLLC #2705448 Name Pacific Convenience and Fuels, LLC Address 3202 W. Hammer Lane, Stockton, CA 95209 Address 2603 Camino Ramon, Ste 350, San Ramon, CA 94583 Phone # 209-957-2900 Phone # 925-884-0827 Contact Belinda Sawyer Contact Compliance Officer A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #1 (Product): Name Walton Engineering, Inc. Address 600 E. Main Street, Stockton, CA 95202 In -Tank Gauging Probe Address P.O. Box 1025, W. Sacramento, CA 95691 Notified May 6, 2010 ❑ Lic # 617238 A, B, Haz Inspector Garrett Backus Model: Contact Richard Walton Phone # 209-468-8257 Piping Sump / Trench Sensor(s) Phone # 916-825-3203 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) Model: B1: TANKS Model: :1 •] F.9» ► F.9 :1 :,.9UI I ITAM Dispenser # : 1-2 ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 3-4 ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Tank #1 (Product): 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 / Trench Sensor(s) Model: ❑ 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: 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 Sensor(s) Model: ❑ 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: :1 •] F.9» ► F.9 :1 :,.9UI I ITAM 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 Histog Report WALTON Signature: ENGINEERING, INC. Technician / Cert #: Tim Minard 5292650 -UT Date: May 20, 2010 Dispenser # : 1-2 ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 3-4 ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 5-6 ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser ❑ ❑ ■ # : 7-8 Dispenser Containment Sensor(s) Model: Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves I ❑ 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 Histog Report WALTON Signature: ENGINEERING, INC. Technician / Cert #: Tim Minard 5292650 -UT Date: May 20, 2010