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! 416 2"d Street <br /> A,Lforda�-lw_qeq� Galt, CA 95632 <br /> (209) 744-0113 Fax (209) 744-0116 <br /> E.O.VR-204 <br /> Veeder-Root In-Station Diagnostics Site Shutdown Test Report Forlrxli <br /> 1 Permit Number: Date of Test: 8-17-11 Time: 12 <br /> Site Name: QUIK SERVE <br /> Site Address: 950 WEST 11TH STREETb � �r <br /> City: TRACY CA Zip: Technician: DAVID WINKLER <br /> Veeder-Root: # 834975 <br /> District: SJVAPCD-N <br /> x <br /> sr tM 4 <br /> a <br /> Was power removed from the TLS-350 console? y <br /> Was power to the submersible pump(s)removed by the TLS-350? y <br /> Was power restored to TLS-350 console? y <br /> NOTES: A certified Veeder-Root technician must perform this test. <br /> /declare, under penalty of perjury under the laws of the state of California that based on information and belief formed after reasonable inquiry, the statements and <br /> information provided in this document are true,accurate,and complete. <br /> Signature of Technician: Date: 8-17-11 <br /> Ver. 1.0-09.18.08 <br />