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MONITgf ING SYSTEM CERTIFWATION MAKE / MODEL OF MONITORING SYSTEM: Gilbarco EMC CERTIFICATION /TEST DATE: July 20, 2009 A1. FACILITY Name Quik Stop Market # 76 Address 1030 S. Olive Avenue, Stockton, CA 95215 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 Dispenser # : 1-2 A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #1 (Product): Gasoline - 87 Name Walton Engineering, Inc. Address 600 E. Main Street, Stockton, CA 95202 In -Tank Gauging Probe Address P.O. Box 1025, W. Sacramento, CA 95691 Notified July 17, 2009 ■ Lic # 617238 A, B, Haz Inspector Jeff Wong Model: 0794380-303 Contact Richard Walton Phone # 209-468-3439 Piping Sump / Trench Sensor(s) Phone # 916-825-3203 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS 132: DISPENSERS/UDC's Dispenser # : 1-2 Dispenser # : 3-4 Tank #1 (Product): Gasoline - 87 Dispenser Containment Sensor(s) Model: 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: FE Petro STP -MLD ■ Mechanical Line Leak Detector Model: FE Petro STP -MLD ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Tank Overfill 1 High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Dispenser # : Dispenser # : Tank #4 (Product): _ Dispenser Containment Sensor(s) Model: 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 / Trench Sensor(s) Model: ❑ Piping Sump / 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 / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: 132: DISPENSERS/UDC'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 WALTON Signature:" (� ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: July 20, 2009 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 WALTON Signature:" (� ENGINEERING, INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: July 20, 2009