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MONIT ING SYSTEM CERTI AT CERTIFICATION /TEST DATE: Jul 2, 2014 JUL 2 8 2014 A1. FACILITY A2. OWNER ENVIRONMENTAL HEAL? JI Name Quik Stop Market # 76 Name Quik Stop Markets, Inc. AR M�j� Address 1030 S. Olive Avenue, Stockton, CA 95215 address 4567 Enterprise Street, Fre®oEn�t, CAT94538' T 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: Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ❑ Yes ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? El No * Was accuracy of system product level readings tested? El Yes El No * Was accuracy of system water level readings tested? [I Yes ❑ No * Were all probes reinstalled properly? ❑ Yes El No * Were all items on the equipment manufacturer's maintenance checklist completed? El _ Yes ElNo* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ■ N/A [I Yes 11No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ■ N/A or disconnected? ❑ Yes C3No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions " In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): El 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? ❑ Yes ❑ No * _ Were all tank gauging probes visually inspected for damage and residue buildup? El Yes El No * Was accuracy of system product level readings tested? El Yes El No * Was accuracy of system water level readings tested? [I Yes ❑ No * Were all probes reinstalled properly? ❑ Yes El No * Were all items on the equipment manufacturer's maintenance checklist completed? G. LINE LEAK DETECTORS (LLD): El 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? El N/A (check all that apply) Simulated leak rate: ■ 3 g.p.h.; El 0.1 g.p.h.; [10.2 g.p.h. ■ Yes E]No* Were all LLDs confirmed operational and accurate within regulatory requirements? ■ Yes ElNo* Was the testing apparatus properly calibrated? ■ Yes 11No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? El N/A El _ Yes ElNo* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ■ N/A [I Yes 11No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ■ N/A or disconnected? ❑ Yes C3No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ■ N/A or fails a test? For electronic LLDs, have all accessible wiring connections been visually inspected? El Yes ❑ NO* ■ N/A Were all items on the equipment manufacturer's maintenance checklist completed? ■ Yes 11No* * In Section H below, describe how and when these deficiencies were or will be corrected. Page 3 of 3