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MONITU#ING SYSTEM CERTIFWATION CERTIFICATION /TEST DATE: August 22, 2011 Al. FACILITY A2. OWNER Name Quik Stop Market #138 Name Quik Stop Markets, Inc. Address 1153 Lincoln Blvd., Tracy, CA 95376 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? El Yes El No* Were all tank gauging probes visually inspected for damage and residue buildup? El Yes El No* Was accuracy of system product level readings tested? ❑ Yes El No* Was accuracy of system water level readings tested? El Yes El No* Were all probes reinstalled properly? * In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): El Check this box if LLDs are not installed. Complete the following checklist: ■ Yes ElNo* 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.; El0.1 g. p. h.; Ll0.2 g. p. h. ■ Yes ElNo* Were all LLDs confirmed operational and accurate within regulatory requirements? ■ Yes ElNo* Was the testing apparatus properly calibrated? ■ Yes ElNo* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? El N/A El Yes ElNo* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ■ N/A El Yes ElNo* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ■ N/A or disconnected? El 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? El Yes ElNo* For electronic LLDs, have all accessible wiring connections been visually inspected? ■ N/A ■ Yes ElNo* 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 Page 3 of 3 * In Section H below, describe how and when these deficiencies were or will be corrected. H. COMMENTS Page 3 of 3