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MONITOING SYSTEM CERTIPWATION MAKE / MODEL OF MONITORING SYSTEM: Gilbarco EMC CERTIFICATION / TEST DATE: Auaust 15. 2013 Al. FACILITY Name Quik Stop Market # 39 Address 2285 E. Fremont Street, Stockton, CA 95205 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 July 30, 2013 ■ Lic # 617238 A, B, Haz Inspector Jeffrey Wong Model: 0794380303 Contact Dulcinea Coven 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 tS2: UI�F+tN1tK,/UUG"S Dispenser # : 1-2 ■ Dispenser Containment Sensor(s) Model: 0847990-001 ■ 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: 0794380-303 ■ Annular Space or Vault Sensor Model: 0794380303 ■ 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 89LD-2000 ■ Mechanical Line Leak Detector Model: VMI 99LD-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 equipment in Section E) Model: Tank #3 (Product): Tank #4 (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: tS2: UI�F+tN1tK,/UUG"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 W rJ WALTON Signature: 01 ENGINEERING, INC. Technician / Cert #: Jessie Wadkins I B35391 5307886 -UT Date: August 15, 2013 Dispenser # : 1-2 ■ Dispenser Containment Sensor(s) Model: 0847990-001 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ■ ■ ❑ # : 3-4 Dispenser Containment Sensor(s) Model: 0847990-001 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 Chains) 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 W rJ WALTON Signature: 01 ENGINEERING, INC. Technician / Cert #: Jessie Wadkins I B35391 5307886 -UT Date: August 15, 2013