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MONIT(WING SYSTEM CERTIIWATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: Mav 24, 2011 A1. FACILITY A2. OWNER Name Quik Stop Market #132 Tank #1 (Product): Gasoline - 87 Name Quik Stop Markets, Inc. Address 3555 W. Hammer Lane, Stockton, CA 95219 In -Tank Gauging Probe Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 ■ Phone # 510-657-8500 Contact Michael Karvelot Model: 0794390-409 Contact Michael Karvelot A3. C U P A ■ Piping Sump / Trench Sensor(s) A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Model: Name Walton Engineering, Inc. Address 600 E. Main Street, Stockton, CA 95202 Mechanical Line Leak Detector Address P.O. Box 1025, W. Sacramento, CA 95691 Notified May 4, 2011 ❑ Lic # 617238 A, B, Haz Inspector Garrett Backus Model: Contact Dulcinea Covan Phone # 209-468-8257 Tank Overfill I High -Level Sensor Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) gi- TANKS B2: DISPENSERSILIDC's Dispenser # : 1-2 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ■ ■ ❑ 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: VMI 99LD-2000 ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill I 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 - 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 I 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: FE Petro STP -MLD ❑ 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: B2: DISPENSERSILIDC'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 Signature: - Technician / Cert #: Curtis Carpenter/ B37258 8020679 WALTON _ ENGINEERING, 'INC. Date: May 24, 2011 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 ■ ■ ❑ # : 7-8 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 Signature: - Technician / Cert #: Curtis Carpenter/ B37258 8020679 WALTON _ ENGINEERING, 'INC. Date: May 24, 2011