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MONIT41tING SYSTEM CERT CATION MAKE / MODEL OF MONITORING SYSTEM: Gilbarco EMC CERTIFICATION /TEST DATE: Jul 29, 2013 Al. FACILITY Name Quik Stop Market #148 Address 205 W. Lockeford Street, Lodi, CA 95240 Phone # 510-657-8500 Contact Michael Karvelot A3. CUPA Name Name San Joaquin County Environmental Health Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Notified July 17, 2013 Inspector Aris Cacapit Phone # 209-468-8257 A2. OWNER Name Quik Stop Markets, Inc. Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Contact Michael Karvelot A4. TESTING CONTRACTOR Name Walton Engineering, Inc. Address P.O. Box 1025, W. Sacramento, CA 95691 Lic # 617238 A, B, Haz Contact Dulcinea Covan Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) R -t- TAMICC C. CERTIFICATION 1 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 ("o I , � o WALTON Signature: —�� "`C ENGINEERING, INC. Technician / Cert M Chris Kuykendall / B42243 8161927 Date: July 29, 2013 Dispenser # : 1-2 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 3-4 ❑ 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) Tank #1 (Product): Gasoline - 87 Tank #2 (Product): Gasoline - 89 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ■ 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) Model: ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: Red Jacket FX ■ 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): Gasoline - 91 Tank #4 (Product): ❑ In -Tank Gauging Probe Model: ❑ 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: VMI 99LD-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: C. CERTIFICATION 1 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 ("o I , � o WALTON Signature: —�� "`C ENGINEERING, INC. Technician / Cert M Chris Kuykendall / B42243 8161927 Date: July 29, 2013 Dispenser # : 1-2 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser # : 3-4 ❑ 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) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chains) C. CERTIFICATION 1 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 ("o I , � o WALTON Signature: —�� "`C ENGINEERING, INC. Technician / Cert M Chris Kuykendall / B42243 8161927 Date: July 29, 2013