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MONIT(&ING SYSTEM CERTIRf ATION MAKE / MODEL OF MONITORING SYSTEM: Gilbarco EMC CERTIFICATION /TEST DATE: August 17. 2006 Al. FACILITY A4. TESTING CONTRACTOR A2. OWNER San Joaquin County Environmental Health Name Quik Stop Market #152 Address Name Quik Stop Markets, Inc. Address 1721 S. Cherokee Lane #1, Lodi, CA 95240 August 1, 2006 Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Contact Phone # 510-657-8500 Contact Michael Karvelot 916-825-3203 Contact Michael Karvelot A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 304 E Weber Avenue, 3rd Floor, Stockton, CA 95202 Address P.O. Box 1025, W. Sacramento, CA 95691 Notified August 1, 2006 Lic # 617238 A, B, Haz Inspector Lori Luces Contact Richard Walton Phone # 209-468-9847 Phone # 916-825-3203 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspectediserviced) B1: TANKS Tank #1Product): Gasoline - 87 ( I Tank #2 (Product): Gasoline - 89 ■ In -Tank Gauging Probe Model: 0847390-109 ■ In -Tank Gauging Probe Model: 0847390-109 ■ 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) ■ Mechanical Line Leak Detector Model: Model: ❑ Fill Sump Sensor(s) Vaporless LD -2000 ■ Mechanical Line Leak Detector Model: Model: Vaporless LD -2000 ❑ 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 a ui pment in Section E) Model: Tank #3 (Product): Gasoline - 91 Tank #4 (Product): ■ In -Tank Gauging Probe Model: 0847390-109 ❑ 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: Vaporless LD -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: 132: DISPENSERS/UDC's Dispenser # : 1-2 Dispenser # : 3-4 ❑ 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) 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 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 �� / p�j� WALTON Signature: '�"�'� E NGINEERING, INC. Technician / Cert #: Bruce N. Stewart / A31131 5249892 -UT Date: August 18, 2006