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MONIT ING SYSTEM CERTI ATION CERTIFICATION /TEST DATE: Jul 13, 2012 A1. FACILITY A2. OWNER Name Quik Stop Market#76 Name Quik Stop Markets, Inc. Address 1030 S.Olive Avenue,Stockton,CA 95215 Address 4567 Enterprise Street,Fremont,CA 94538 Phone# 510-657-8500 Phone# 510-657-8500 Contact Michael Karvelot Contact Michael Karvelot F. IN-TANK GAUGING/SIR EQUIPMENT: ■ Check this box if tank gauging is used only for Inventory control. ❑ Check this box If no tank gauging or SIR equipment is installed. This section must be completed if in-tank gaugung equipment is used to perform leak detection monitoring. Complete the following checklist: ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination,including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually Inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of system product level readings tested? ❑ Yes ❑ No* Was accuracy of system water level readings tested? ❑ Yes ❑ No* Were all probes reinstalled properly? ❑ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below,describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS(LLD): ❑ Check this box if LLDs are not installed. Complete the following checklist: ■ Yes ❑ No* For equipment start-up or annual equipment certification,was a leak simulated to verify LLD performance? ❑ N/A (check all that apply) Simulated leak rate: ■ 3 g.p.h.; ❑ 0.1 g.p.h.; ❑ 0.2 g.p.h. ■ Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? ■ Yes ❑ No* Was the testing apparatus properly calibrated? ■ Yes ❑ No* For mechanical LLDs,does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? ■ N/A ❑ Yes ❑ No* For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled ■ N/A or disconnected? ❑ Yes ❑ No* For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions ■ N/A or fails a test? ❑ Yes ❑ No* For electronic LLDs,have all accessible wiring connections been visually inspected? ■ N/A ■ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below,describe how and when these deficiencies were or will be corrected. H. COMMENTS ©2012 Walton Engineering,Inc. Page 3 of 3