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MONITIG&ING SYSTEM CERTIFWATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION /TEST DATE: December 16, 2009 Al. FACILITY A2. OWNER Name Bonfare Market#35 Name Bonfare Markets, Inc. Address 15 W.Grant Line Road,Tracy,CA 95376 Address 461 S.Milpitas Blvd.,Suite 1,Milpitas,CA 95035 Phone# 209-833-9619 Phone# 408-933-4422 Contact Danny Arcayena Contact Sean Kapoor A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 600 E. Main Street,Stockton,CA 95202 Address P.O. Box 1025,W.Sacramento,CA 95691 Notified December 10,2009 Lic# 617238 A,B, Haz Inspector Michell Henry Contact Richard Walton Phone# 209-468-3439 Phone# 916-825-3203 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS Tank#1 (Product): Gasoline -91 Tank#2 (Product): Gasoline-87 1 ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ■ Fill Sump Sensor(s) Model: 0794380-208 ■ Fill Sump Sensor(s) Model: 0794380-208 ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ■ Electronic Line Leak Detector Model: 0848480-001 ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill I High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank#3 (Product): Gasoline -87 2 Tank#4 (Product): _ ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-420 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ❑ Piping Sump I Trench Sensor(s) Model: ■ Fill Sump Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ■ Electronic Line Leak Detector Model: 0848480-001 ❑ 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: DISPENSERS/UDC's Dispenser#: 1-2 Dispenser#: 3-4 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) Dispenser#: 5-6 Dispenser#: Vent box ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ 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,1 have also attached a copy of the report; (check all that apply): ■ System set-up ■ Alarm History Report I(�1 N11 WALTON Signature: +J/KAX ENGINEERING,INC. Technician I Cert#: Bruce N.Stewart/A31131 5249892-UT Date: December 16, 2009 ©2006 Walton Engineering,Inc.