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MONITORING SYSTEM CERTIFICATION JUL 0 8 2016 MAKE/ MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 _ CERTIFICATION /TEST DATE: July 7, 2016 A1. FACILITY A2. OWNER Name Quik Stop Market#76 Name Quik Stop Markets, Inc. Address 1030 S.Olive Avenue,Stockton,CA 95215 Address 4567 Enterprise Street,Fremont,CA 94538 Phone# 510-657-8500 Phone# 510-657-8500 { Contact Roger Batra Contact Debbie Markovich A3. C UP 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 July 5,2016 Lic# 617238 A,B,Haz Inspector Yes 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) ` B1: TANKS Tank#1 (Product): 87 Tank#2 (Product): 91 M' sa ❑ In-Tank Gauging Probe Model: g ❑ In-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794380-303 ■ Annular Space or Vault Sensor Model: 0794380-303 ■ 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: 99 LD2000 ■ Mechanical Line Leak Detector Model: FE Petro STP-MLD ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: t: ❑ Tank Overfill I High-Level Sensor Model. ❑ Tank Overfill/High-Level Sensor Model: El (specify equipment in Section E) Model El Other (specify equipment in Section E) Model Tank#3 (Product): Tank#4 (Product): ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: 71 j' ❑ Piping Sump/Trench Sensor(s) Model: ❑ Piping Sump/Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: E] 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: 132: 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 Chains) 5,04 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) ti. 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) 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 th 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 ❑ S stem set-up ❑ Alarm History Report WALTON Signature: NGINEERING,INC. Technician/Cert M Scott Beall/B46116 8319310 Date: filly 7>2016 : �n 0 2016 Walton Engineering,Inc.