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MONITSRING SYSTEM CERTHWATION MAKE /MODEL OF MONITORING SYSTEM: Gilbarco EMC CERTIFICATION /TEST DATE: June 19, 2012 Al. FACILITY Name Quik Stop Market #125 Address 1580 W. Main Street, Ripon, CA 95366 Phone # 510-657-8500 Contact Michael Karvelot A2. OWNER Name Quik Stop Markets, Inc. Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Contact Michael Karvelot A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #1 (Product): Gasoline - 87 Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 In -Tank Gauging Probe Address P.O. Box 1025, W. Sacramento, CA 95691 Notified June 13, 2012 ■ Lic # 617238 A, B, Haz Inspector Muniappa Naidu Model: 0794390-409 Contact Dulcinea Covan Phone # 209-468-8257 Piping Sump / Trench Sensor(s) Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to indicate equipment inspected/serviced) B1 - TANKS B2' OISPFNSFRS/IInC'st Dispenser # : 1-2 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser ❑ ■ ■ 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: 0794390-409 ■ Annular Space or Vault Sensor Model: 0794390-409 ■ 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 Tank Overfill / High -Level Sensor Model: Model: ❑ ❑ Electronic Line Leak Detector Tank Overfill / High -Level Sensor Model: 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: ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-409 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) _ Model: 0794380-208 ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ 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' OISPFNSFRS/IInC'st 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 `-• \ WaX- WALTON Signature: oV U1 ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: June 19, 2012 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 ❑ ❑ ❑ # 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 ❑ 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 `-• \ WaX- WALTON Signature: oV U1 ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: June 19, 2012