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r A MONITORING SYSTEM CERTIFICATI JUL 09 ?_015 CERTIFICATION / TEST DATE: July 1, 2015 Al. FACILITY A2. OWNER m r� ryCp�1RTAACnIT Name (luck Stop Market # 76 Name Ouik Stop Markets, Inc.14Cp 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 F. IN -TANK GAUGING / SIR EQUIPMENT: ■ Check this box if tank gauging is used only for inventory control. ❑ Check this box If no tank gauging or SIR equipment is installed. This section must be completed If in -tank gaugung equipment is used to perform leak detection monitoring. Complete the following checklist: * In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): ❑ Check this box if LLDs are not installed. Complete the following checklist: ■ Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ❑ N/A (check all that apply) Simulated leak rate: ■ 3 g.p.h.; ❑ 0.1 g.p.h.; ❑ 0.2 g.p.h. ■ Yes ❑ No * Were all LLDs confirmed operational and accurate within regulatory requirements? ■ Yes ❑ No ' Was the testing apparatus properly calibrated? ■ Yes ❑ No ' For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ■ N/A ❑ Yes ❑ No * For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ■ N/A or disconnected? ❑ Yes ❑ No' For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ■ N/A or fails a test? ❑ Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ■ N/A ■ Yes ❑ No' Were all items on the equipment manufacturer's maintenance ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of system product level readings tested? ❑ Yes ❑ No * Was accuracy of system water level readings tested? ❑ Yes ❑ No * Were all probes reinstalled properly? ❑ Yes ❑ No * Were all items on the equipment manufacturer's maintenance * In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): ❑ Check this box if LLDs are not installed. Complete the following checklist: ■ Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ❑ N/A (check all that apply) Simulated leak rate: ■ 3 g.p.h.; ❑ 0.1 g.p.h.; ❑ 0.2 g.p.h. ■ Yes ❑ No * Were all LLDs confirmed operational and accurate within regulatory requirements? ■ Yes ❑ No ' Was the testing apparatus properly calibrated? ■ Yes ❑ No ' For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ■ N/A ❑ Yes ❑ No * For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ■ N/A or disconnected? ❑ Yes ❑ No' For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ■ N/A or fails a test? ❑ Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ■ N/A ■ Yes ❑ No' Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): ❑ Check this box if LLDs are not installed. Complete the following checklist: ■ Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ❑ N/A (check all that apply) Simulated leak rate: ■ 3 g.p.h.; ❑ 0.1 g.p.h.; ❑ 0.2 g.p.h. ■ Yes ❑ No * Were all LLDs confirmed operational and accurate within regulatory requirements? ■ Yes ❑ No ' Was the testing apparatus properly calibrated? ■ Yes ❑ No ' For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ■ N/A ❑ Yes ❑ No * For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ■ N/A or disconnected? ❑ Yes ❑ No' For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ■ N/A or fails a test? ❑ Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ■ N/A ■ Yes ❑ No' Were all items on the equipment manufacturer's maintenance * In Section H below, describe how and when these deficiencies were or will be corrected. H. COMMENTS Page 3 of 3 checklist completed? * In Section H below, describe how and when these deficiencies were or will be corrected. H. COMMENTS Page 3 of 3