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MONITORING SYSTEM CERTIFICATION CERTIFICATION / TEST DATE: September 21, 2012 Al. FACILITY Make / Model of Monitoring System: Veeder-Root TLS -350 A2. OWNER Complete the following checklist: Name Quik Stop Market #148 Name Quik Stop Markets, Inc. Address 205 W. Lockeford Street, Lodi, CA 95240 ❑ Yes E❑ Address 4587 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Yes Phone # 510-657-8500 Contact Michael Karvelot ❑ No' Contact Michael Karvelot will not interfere with their proper operation? If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modems) D. RESULTS OF TESTING 1 SERVICING Make / Model of Monitoring System: Veeder-Root TLS -350 Software Version Installed: Complete the following checklist: �❑ ❑ Yes E❑ No' ' Is the audible alarm operational? Yes ❑ No' Is the visual alarm operational? Were all sensors visually Inspected, functionally tested, and confirmed operational? ❑ Yss ❑ No ❑ No' ❑ Yes Were all sensors Installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modems) ❑ Yes ❑ No " ❑ NIA operational? For pressurized piping systems, does the turbine automatically shut down If the piping secondary containment ❑ Yes ❑ No" ❑ NIA monitoring system detects a leak, fails to operate, or Is electrically disconnected? If yes: which sensors initiate positive shutdown? (check all that apply) ❑ Sumprrrench sensors; ❑ Dispenser Containment Sensors. ❑ Yes ❑ No* I Did you confirm positive shut -down due to leaks &n sensor failureldisconnection? ❑ Yes ❑ No " For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no ❑ NIA mechanical overfill prevention valve is Installed), is the overfill warning alarm visible and audible at the tank fill point(s) and operating properly? If so, at what percent of tank capacity does the alarm trigger? _ % Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaced ❑ Yes " ❑ No and list the manufacturer name and model for all replacement parts In Section E, below. Was any liquid found Inside any secondary containment systems designed as dry systems? ❑ Yes " ❑ No 3(Check all that apply) ❑ Product; ElWater. If yes, describe causes In Section E, below. ❑_ Yea ❑ No " Was monitoring system set-up reviewed to insure proper settings? Attach set-up reports, if applicable. Is all monitoring_. equipment operational per manufacturers specifications? ❑ Yes ❑ No " ' In Section E below, describe how and when these deficiencies were or will be corrected. E. COMMENTS Page 2 of 3