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T 'MONITORING SYSTEM CERTIMATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: December 16, 2009 A1. 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) 1211- TANKS 1:VN=11RIUA01117I:3Z+:f1111%oin Dispenser # : 1-2 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ■ ■ ❑ # : 3-4 Dispenser Containment Sensor(s) Model: 0794380-208 Shear Valves Dispenser Containment Float(s) and Chain(s) Tank #1 (Product): Gasoline - 91 Dispenser # : 5-6 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Tank #2 (Product): Gasoline - 87 1 # : Vent box Dispenser Containment Sensor(s) Model: 0794380-208 Shear Valves Dispenser Containment Float(s) and Chain(s) ❑ In -Tank Gauging Probe Model: Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ in -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-420 ■ Annular Space or Vault Sensor Model: 0794390420 ■ 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 / 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 / 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: 1:VN=11RIUA01117I:3Z+:f1111%oin 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 . ALTON Signature: ENGINEERING, INC. Technician / Cert #: Bruce N. Stewart / A31131 5249892 -UT Date: December 16, 2009 Dispenser # : 1-2 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ■ ■ ❑ # : 3-4 Dispenser Containment Sensor(s) Model: 0794380-208 Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : 5-6 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ■ ❑ ❑ # : Vent box Dispenser Containment Sensor(s) Model: 0794380-208 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) 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 . ALTON Signature: ENGINEERING, INC. Technician / Cert #: Bruce N. Stewart / A31131 5249892 -UT Date: December 16, 2009