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tesvm � d MONITORING SYSTEM CF TIFIC MAKE I MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 J U N 2, 1, 2017 CERTIFICATION /TEST DATE: June 16, 2017 A1. FACILITY A2. OWNER ' `� Name Quik Stop Market#124 Name Quik Stop Markets, Inc. DEPARTIMENT Address 505 N.Main Street,Manteca,CA 95336 Address 4567 Enterprise Street,Fremont,CA 94538 Phone# 510-657-8500 Phone# 510-657-8500 Contact Roger Batra Contact Debbie Markovich A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering,Inc. Address 1868 E.Hazelton Avenue,Stockton,CA 95202 Address P.O.Box 1025,W.Sacramento,CA 95691 Notified June 2,2017 Lie# 617238 A,B,Haz Inspector John Alaniz Contact Veronica Freitas Phone# 209-468-3442 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) 131: TANKS 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: FE Petro STP-MLD ® Mechanical Line Leak Detector Model: Red Jacket FX ❑ 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: I� 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: E12: DISPENSERS/UDC's Dispenser#: 1-2 Dispenser#: 3-4 ❑ 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) 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 Chains) 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) Eli RTIFICATION i certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines. to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing th 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 ALroN Signature: A 6I IZ` — ENGINEERING,MC, Technician/Cert M Anthony Reyes B45115 8293772 Date: June 16, 2017 ©2017 Walton Engineering,Inc.