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MONITQ#ING SYSTEM CERTIFWATION MAKE / MODEL OF MONITORING SYSTEM: Gilbarco EMC CERTIFICATION /TEST DATE: August 15, 2011 Al. FACILITY INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) A2. OWNER Name Quik Stop Market # 39 Name Quik Stop Markets, Inc. Address 2285 E. Fremont Street, Stockton, CA 95205 Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Phone # 510-657-8500 Contact Michael Karvelot ❑ Contact Michael Karvelot A3. C U P A ❑ In -Tank Gauging Probe A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health ■ Name Walton Engineering, Inc. Address 600 E. Main Street, Stockton, CA 95202 Annular Space or Vault Sensor Address P.O. Box 1025, W. Sacramento, CA 95691 Notified August 10, 2011 Piping Sump / Trench Sensor(s) Lic # 617238 A, B, Haz Inspector Muniappa Naidu Model: 0794380-208 Contact Dulcinea Covan Phone # 209-468-8257 Model: 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: ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794380-303 ■ Annular Space or Vault Sensor Model: 0794380-303 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ 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: Tank #4 (Product): _ Tank #3 (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 Sensor(s) Model: ❑ Piping Sump I 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 I High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: 132: DISPENSERS/UDC's Dispenser # : 1-2 Dispenser # : 3-4 ■ Dispenser Containment Sensor(s) Model: 0847990-001 ■ Dispenser Containment Sensor(s) Model: 0847990-001 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) C. CERTIFICATION I certify that the equipment identified in this document was inspectedlserviced 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 Signature: GAG G WALTON _-- ENGINEERING, INC. I I Technician / Cert #: Curtis Carpenter / B37258 8020679 Date: August 15, 2011 I I a